Emergency On-Call Program Provider Application

General Information

Languages Spoken

Please check all the languages you speak:

Enrollment & Background Check

Have you completed the Independent Provider (IP) enrollment with the IHSS Program?


Have you cleared the background check through the California Department of Justice (DOJ)?


Are you currently enrolled with the San Francisco Public Authority's Provider Registry?


Who referred you to the Public Authority?

On-Call Provider Eligibility

Do you have 1+ years of Homecare and/or Hospice care experience?


Do you have a recent TB clearance or able to provide one before onboarding?


Are you willing to work a minimum of 2 days per week for at least a 3-hour shift per day?


Are you willing to travel to all neighborhoods within San Francisco City limits?


Are you willing to provide personal care assistance (bathing, dressing, bowel and bladder care (diaper changes), transferring) and domestic services (cooking, shopping, laundry) to people who are elderly or disabled and live in their own homes?


Are you willing to use your personal smart phone for work related use (reimbursement payment is provided)?


Are you willing to complete work training on a yearly basis?

If you answered NO to any of the questions above, you are ineligible to apply for the Emergency On-Call position. Please call the On-Call Coordinator should you have any questions at (415) 593-8123 or email: iselskaya@sfihsspa.org

Training & Certification

Please checkmark any of the trainings below if completed within the last 5 years:

Completion Date:

Completion Date:

Expiration Date:

Name(s) of Trainings / Certification:

Work Preferences

Most consumers need part-time work. You can accept emergency assignments that fit your schedule and decline others.

What are the number of hours per week you would be willing to work?


Please check all the times you are available to work for at least 3 hours.

Mornings

Afternoons

Evenings

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you able and willing to work in a home with pets?

Are you able and willing to work in a home that uses scents?


Work History

Please list names of your current or previous Employer(s) and/or Consumer(s) you have provided personal care for.


Period of Employment: (Starting date to ending date.)


From:

To:


Period of Employment: (Starting date to ending date.)


From:

To:


Period of Employment: (Starting date to ending date.)


From:

To:

Optional Information

This section is OPTIONAL but may provide useful information to the Registry. Gender will be used only when a consumer requests a worker of the same gender to provide personal care.

Birthdate:

Gender:

Sexual Orientation:

Ethnicity: