Independent Choices Program Employee Provider Information

Developmental Disabilities Employer/Personal Support Worker/ Domestic Employee Information Employer/participant profile Name: Date of birth:

Mailing address: Phone number:

Physical address: Services coordinator or personal agent:

Prime number: Services coordinator or personal agent phone number: Personal support worker/domestic employee profile #1 Name: Social Security Number:

Mailing address: Date of birth:

Physical address: Phone number:

Program: New hire: Original hire date: Hourly wage rate: Monthly wage (if applicable): Yes No Name of brokerage/CDDP: Start date: End date:

Please check the types of Community living supports Shift during work days: services provided by this Homemaker/chore services From: employee. Please see details Non-medical transportation a.m. p.m. Community inclusion for each of the areas on the To: next page. supports Other: a.m. p.m. Regular scheduled days off:

Mon Tues Wed Thurs Fri Sat Sun Personal support worker/domestic employee profile #2 Name: Social Security number:

Mailing address: Date of birth:

Physical address: Phone number:

New hire: Original hire date: Hourly wage rate: Monthly wage: Yes No

of 2 SDS 0550 (12/10) Provider change: Start date: End date: Yes No Please check the types of Community living supports Shift during work days: services provided by this Homemaker/chore services From: employee. Please see details non-medical transportation a.m. p.m. for each of the areas on the Community inclusion To: last page. supports a.m. p.m. Other: Regular scheduled days off:

Mon Tues Wed Thurs Fri Sat Sun Please check all of the services that your employees provide. If an approved activity is not included, please write in the service in the “other services provided” column.

2 1 2 1 2 1 2 1 2

Community Homecare/ Non-medical Community inclusion Other # # # # # # # # #

e e e e living chore transportation e e supports e services e e e e e e e e e e e e e

supports y services y y (please check all y y (List a sample of y y provided by y y y o o o o o o o o o l l l l l l l l l o l that apply) activities in the your p p p p p p p p p p

m m m m m box below) m m m m

m employee E E E E E E E E E E (write in) Eating Giving and Drives your Activities setting up vehicle supporting medications independence and community inclusion Bathing House- Escorts you in keeping your vehicle chores Dressing Laundry Escorts you on Individual choice public of activities transportation Personal Special Drives you in hygiene diet/meal their car preparation Mobility Shopping Respite services

Socialization

Community participation Communi- cation Personal environ- mental skills

Employee signature #1 Date

Employee signature #2 Date

Employer/representative signature Date

of 2 SDS 0550 (12/10)