<p> For Office Public Authority Use Only Accepted ____/____/____ Public Authority Verified by: ______Registry Application Butte County In-Home Supportive Services</p><p>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 </p><p>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:</p><p>Name: Refrence Name Phone #: ( ) - Relationship: Years Known: Training Expiration I Have Previous Geriatric Aide Experience Certification(s): Date: First Aid / / Describe Other Training: </p><p>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)</p><p>Children Willing to Do: Willing to do: Experienced: Adults Cooking Exercise Elderly Light Cleaning Medications Men</p><p>Women Heavy Cleaning Lifting/Transferring</p><p>Infectious Disease Shopping/Errands Feeding</p><p>Terminally Ill Laundry Bathing Developmentally Disabled Medical Dressing Alzheimer’s Appointments Menstrual Care Dementia Meal Cleanup Bladder Care Brain Injury</p><p>Stroke Bowel Care</p><p>Mentally Ill Paramedical</p><p>Couples Optional Notes on Above IHSS Experience: </p><p>AIDS/HIV</p><p>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: </p><p>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: ___/___/____</p><p>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 </p><p>Forest Ranch</p><p>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.</p><p>I am willing to have a criminal/fingerprint background check: YES NO INITIAL: ___</p><p>Further, regarding this application to participate on the Public Authority Registry:</p><p>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. </p><p>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.</p><p>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.</p><p>I understand that Registry Staff will conduct a background check on me using publicly available resources.</p><p>I understand that the information on this questionnaire may also be shared with prospective employers and their advocates without further notice. </p><p>I understand completing this application and being listed on the Registry does not guarantee me employment.</p><p>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.</p><p>I further understand that an IHSS Consumer-Employer retains the exclusive right to hire, supervise, and terminate my employment with or without notice.</p><p>I understand that I may by written request ask that my name be deleted from participation on the Public Authority Registry.</p><p>Signature: ______Date ______</p><p>Print Name: ______</p><p>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</p>