For Office Public Authority Use Only Accepted ____/____/____ Public Authority Verified by: ______Registry Application Butte County In-Home Supportive Services

Name: Gender: Male Type Last Name Type First Name M.I. Female Birth Date: / / Physical Address: Type Street Address For Statistical Purposes Only City, State, Zip: City State Zip Code Ethnicity: Decline to State Religion: Decline to State Mailing Address (if different): Type in Mailing Address

Social Security #: - - Telephone: If the number is “blocked” and you need to Language Skills: dial *82, please indicate. Also, identify the type of English Skills - Fluent number just below, i.e. home, cell, pager, work, or other. Limited Very Limited Home Phone Home Phone Home Phone No English Speak but do not read ( ) - ( ) - ( ) - Best Language: English Contact Info/Notes: Other Languages Spoken: None (Section Below to Be Completed By Staff During References (Please, No Relatives) Interview) ID Type : CA DL  CA ID  Green Card Two Past Employers:  Military  Passport  Other ______# ______expiration : / / 1. Name/Job Title: Refrence Name Issuing Agency: ______Job Title Phone #: ( ) - Employed From: / / To: / / 2. Name/Job Title: Refrence Name Status of provider applicant medical insurance: Job Title Phone #: ( ) -  Yes, MediCal Yes, Other  No Insurance Employed From: / / To: / /  No Information/Decline to Disclose Personal:

Name: Refrence Name Phone #: ( ) - Relationship: Years Known: Training Expiration I Have Previous Geriatric Aide Experience Certification(s): Date: First Aid / / Describe Other Training:

CPR / / Some of your duties as a caregiver for an In-Home Supportive Services consumer may require you to lift, bend, C.N.A / / stretch, and may require your physical endurance. Are there (Certified Nursing Assistant) any reasons you would not be able to perform duties that CHHA / / require lifting, bending, or stretching? Yes No (Certified Home Health Aide) Explain: HCC / / (Home Care Certification) Client Types (Check all that apply) Domestic Tasks Personal Tasks Willing to work for: Experienced with: (Check all that apply) (Check all that apply)

Children Willing to Do: Willing to do: Experienced: Adults Cooking Exercise Elderly Light Cleaning Medications Men

Women Heavy Cleaning Lifting/Transferring

Infectious Disease Shopping/Errands Feeding

Terminally Ill Laundry Bathing Developmentally Disabled Medical Dressing Alzheimer’s Appointments Menstrual Care Dementia Meal Cleanup Bladder Care Brain Injury

Stroke Bowel Care

Mentally Ill Paramedical

Couples Optional Notes on Above IHSS Experience:

AIDS/HIV

Hepatitis Hours willing to work Special Availability Health & Behavior (Check all that apply) per week 10 hours or less Holidays Smoking 10 to 25 hours Occasional overnights I smoke 25 hours or more Live – In care I am willing to smoke outside at work 1 – 2 hour shifts I am willing to work for a consumer who Available Term On Call smokes Short Term Weekday Evenings Long Term Weekends Allergies Time Periods I am Available for Work: I am allergic to cats Mon Tue Wed Thur Fri Sat Sun I am allergic to dogs Mornings I am allergic to fragrances Afternoons I won’t use scented products at work Evenings Other allergies Overnights Notes:

Accessibility Please check all the areas you are willing to work in: I will use my own car to transport consumers Chico Honcut I use Public Transportation I am willing to drive a consumer’s car Oroville Richvale I will supply a DMV record TB test in the last 12 months Date Paradise Nelson * T.B. Test is recommended but not required. Magalia Yankee Hill **The Public Authority advises all Caregivers to use Universal Precautions (health and safety Upper Ridge standards). Contact us at (530)538-5262 for more information on Universal Precautions. Durham For office use Dayton Fingerprinted on: ___/___/____

Gridley I have never been convicted of a felony Biggs I have a felony conviction(s) List and Give Dates of all Felony conviction(s): Palermo

Forest Ranch

Berry Creek I have Drug or Alcohol Problem(s) (including DUI convictions) Bangor Explain: POLICY AND PROCEDURE ON BACKGROUND CHECKS  All registry applicants will be required to give written permission for the Public Authority to conduct a criminal background check. Refusal to give permission for a criminal/fingerprint background check will result in immediate disqualification from the Public Authority Registry;  All registry applicants will be required to disclose information on previous criminal convictions;  Staff will explain the Public Authority criminal background policy and procedure to all registry applicants; and all registry applicants will be given a copy of the Public Authority criminal background policy and procedure;  A criminal background check will be conducted on each registry applicant prior to placing him/her on the registry.

I am willing to have a criminal/fingerprint background check: YES NO INITIAL: ___

Further, regarding this application to participate on the Public Authority Registry:

I certify under penalty of perjury that all the information provided in this application and its related process is true. I understand that any false or with held information may eliminate me from eligibility for participation on the Public Authority Registry.

I understand that my name may be placed on a list to be given to persons who are seeking assistance in their homes, without further notice.

I understand The Public Authority retains the exclusive right to list, refer with or without comment, suspend, or remove an individual provider from the registry.

I understand that Registry Staff will conduct a background check on me using publicly available resources.

I understand that the information on this questionnaire may also be shared with prospective employers and their advocates without further notice.

I understand completing this application and being listed on the Registry does not guarantee me employment.

I understand that my employer is not Butte County In-Home Supportive Services (“IHSS”) or the Butte County IHSS Public Authority. The IHSS consumer is my employer.

I further understand that an IHSS Consumer-Employer retains the exclusive right to hire, supervise, and terminate my employment with or without notice.

I understand that I may by written request ask that my name be deleted from participation on the Public Authority Registry.

Signature: ______Date ______

Print Name: ______

Remember to call the Registry every two weeks to update your availability at (530) 538-5262. If you do not, you will be made inactive and your name will not be referred to IHSS consumers. Provider Applicant May Attach Additional References