ULTCW

Homecare excHange
application Form For providers

(You can also submit your application online at HomeCareExchange.org, or by calling: 1-866-544-5742)

NAME EMAIL
ADDRESS

CITY

STATE

ZIP
CELL PHONE HOME PHONE

SOCIAL SECuRITY #

CA ID / DRIVER’S LICENSE #

GENDER:

____FEMALE

____MALE

DATE OF BIRTH (OPTIONAL) ______/______/______

What languages do you speak? Primary Secondary Other

Please check the tasks you are capable of and willing to perform for the care recipient: Accompany to Dr. appoint. Ambulation Exercises Bathing Bed Baths Bowel and Bladder Care Bowel Program Cleaning Cooking Dressing Errands Feeding Grooming Heavy Cleaning Ironing Laundry Medication Dispensation Menstrual Care Prosthetic Assistance Protective Supervision Repositioning and Skin Care Service Animals Shopping Wheelchair Assistance

Any experience and/or training in the following? Please check all that apply. Alzheimer’s Disease Arthritis Asthma Cancer Certified Nurse’s Aide CPR Dementia Diabetes Feeding Tubes First Aid Heart Condition Home Health Aide HIV/AIDS Hypertension Homecare Worker Training Insulin care Licensed Vocational Nurse Are you willing to avoid using scented fragrances on the job? Are you willing to work for a care recipient with a dog? Are you willing to work for a care recipient with a cat? Are you willing to work at a home where there is a smoker? Yes Yes Yes Yes No No No Yes No No Mental / Emotional Disability Multiple Sclerosis Paralysis Parkinson’s Disease Range of Motion Respiration Assistance Registered Nurse Seizures Special Diet Spinal Bifida Spinal Cord Injury Stroke Thalamic Brain Injury Visual Impairment Vital Signs Wound Care

Are you willing to comply with a no-smoking rule at your care recipient’s home? How many hours are you currently working? How many additional IHSS hours do you wish to work? Would you be willing to work for a non-IHSS (private pay) client? Do you have a car that can be used for work? Yes No Yes per month.

per month. No

times oF availaBilitY Check the days and times when you might be willing to schedule services by entering a “ YES ” or “ NO ” where applicable.

MON. MORNING AFTERNOON EVENING OVERNIGHT LIVE-IN ON-CALL

TuES.

WED.

THuRS.

FRI.

SAT.

SuN.

Will you be available to work in an emergency or on call?

Yes

No

educational Background (Write highest level reached/subject area within each category) Grade School College Major Middle School

personal reFerences (Do not include relatives) Name Address Primary phone What is your relationship to this person? Name Address Primary phone What is your relationship to this person?

Homecare emploYment HistorY Please list below each care recipient you have worked for within the last three years. Name of care recipient Date: From Reason for ending service Phone number of care recipient (if available) (If care recipient not available) Name and phone number of recipient family member: To

Name of care recipient Date: From Reason for ending service Phone number of care recipient (if available) (If care recipient not available) Name and phone number of recipient family member: To

Name of care recipient Date: From Reason for ending service Phone number of care recipient (if available) (If care recipient not available) Name and phone number of recipient family member: To

Name of care recipient Date: From Reason for ending service Phone number of care recipient (if available) (If care recipient not available) Name and phone number of recipient family member: To

Name of care recipient Date: From Reason for ending service Phone number of care recipient (if available) (If care recipient not available) Name and phone number of recipient family member: To

I certify under penalty of perjury that the information provided above is true to the best of my knowledge. I also understand that any misrepresentation on my part may result in disqualification or removal from the Homecare Exchange at any time. I further authorize the Homecare Exchange and/or the care recipient to contact the above employers and references concerning my work and character. Signature Date

IMPORTANT You must submit the following documents along with your application. If you do not submit all the following documents, we cannot process your application. 1) Photocopy of the letter from the Personal Assistance Service Council (PASC) stating either that you passed your background check; or that you are not required to undergo a new background check. 2) Photocopy of your California driver’s license or identification card 3) Photocopy of your social security card 4) Photocopy of a check stub with a deduction for union dues

FOR OFFICE USE ONLY
Participant’s Right, Responsibilities and Release Form signed and received? Date Processed By Yes No

Employment History checked by References checked by

Date Date

please read careFullY
PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE Note: This Agreement contains important provisions regarding the nature of Homecare Exchange services, the Independent Provider Mode, the duties of Homecare Exchange participants, and the Release of the Homecare Exchange, its affiliates and agents from any liability. Homecare Exchange 1. Nature of Homecare Exchange Services: SEIu, The united Long-Term Care Workers’ union, Provides this union Provider Homecare Exchange at no cost to the Provider or Care recipient, for the express purpose of facilitating and/or assisting in the development of the employment relationship between the Provider and potential Care recipient. However, the decision of whether to employ any potential Provider applicant is solely at the discretion and control of the Care recipient. Homecare Exchange services are entirely optional and voluntary. The Homecare Exchange shall require that all Provider applicants comply with all state laws and regulations required for their services as a Provider (including all required background checks). However, the Homecare Exchange is not responsible for any further or independent verification of whether the Provider has actually met all the conditions, beyond the normal presentation of documents indicating that such requirements have indeed been met. Beyond this initial screening process, the Homecare Exchange does not perform any additional evaluation, interviews, or other means of verify or vouching for the quality of the Provider Homecare Exchange applicant. Therefore, it is essential that the Care recipient conduct his/her own evaluation of the Provider prior to establishing the employment relationship. Further, the Homecare Exchange does not warrant the quality of the applicant or his or her abilities to carry out the duties required by the Care recipient. The Homecare Exchange will, however, conduct some limited matching of the Provider to the stated needs of the Care recipient profile. Any Care recipient and applicant Provider therefore must use their own judgment and make their own decisions regarding one another’s skills, character and compatibility, and as to how well they may meet each other’s needs. The Care recipient and Provider assume and accept the risk of such decisions. 2. Independent Provider Mode of Service: When a Care recipient offers employment to a Provider, and the Provider has accepted such employment the Provider becomes the Care recipient’s employee. In accordance with the law and County DPSS requirements and guidelines, the Care recipient has sole authority to hire, assign hours and duties, direct the work, supervise, evaluate, and choose whether to continue or terminate the Provider’s services. Likewise, the Provider retains the right to resign such employment at any time without notice or cause. The Homecare Exchange has no authority or responsibility for any such matters or for any injuries or damages which may arise out of the referral or which may arise out of the employment, or for investigating or resolving any disputes, misunderstandings or injuries which may arise between a Care recipient and a Provider or any third party. RIGHTS, RESPONSIBILITIES AND RELEASE ( 3 )

Receipt and use of Personal Information. As part of its operations, the Homecare Exchange may seek and/or receive information concerning Homecare Exchange participants, including information furnished by the Care recipient about his or her needs, or employment and personal information from references (or others) of a confidential or sensitive nature. The Homecare Exchange may share such information with others for Homecare Exchange purposes, or investigate or act upon such information to grant or deny referrals, or to suspend, exclude or remove a Provider or Care recipient from Homecare Exchange participation, through confidential procedures. Any disputes concerning any such uses or related decisions are to be determined by the Homecare Exchange Management Committee. The decisions of the Homecare Exchange Management Committee are final and binding upon all concerned, including Homecare Exchange staff and any involved Care recipient (s) and/or Provider(s), and are not to be the subject of any further proceedings or litigation of any nature. 6. Participant Responsibilities: Homecare Exchange participant and services are a revocable privilege and not a right. The Homecare Exchange Management Committee can terminate the participation of any Provider or Care recipient at any time it deems appropriate and necessary. Each participant (Provider or Care recipient) is expected and required, as an ongoing condition of Homecare Exchange participation: (a) To comply with all Homecare Exchange policies, procedures and directives, and to cooperate fully with Homecare Exchange personnel; (b) To pursue all referrals diligently, by prompt follow-up, to attend all agreed upon interviews and other appointments, and to keep the Homecare Exchange updated as to all decisions; and (c ) To treat Homecare Exchange staff and all other Homecare Exchange participants with civility and respect. PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE ( 4 ) PARTICIPANT’S RELEASE: The undersigned Homecare Exchange participant hereby releases the Homecare Exchange from any claim, damages, injuries, liability or remedy of any nature relating in any way to the Homecare Exchange, its services or denial of services, or its actions or failures to act. This includes any injuries suffered while seeking employment or considering referrals, or while providing or receiving home assistance services or acting as employer of Provider, the undersigned will not make any claims (or seek any remedy) against the Homecare Exchange. The above Release applies to, Homecare Exchange SEIu uLTCW, the County of Los Angeles, affiliated agencies such as those furnishing emergency/respite services to Care recipients, the individual officers, governing board members, agents, employees, representatives, advisers, insurers and volunteers of the Homecare Exchange and of such related and affiliated entities, and each of them, and all entities and persons who have furnished information or otherwise cooperated with the Homecare Exchange. This Release is made on behalf of the undersigned participant’s personal representatives, family, heirs, dependents, community property and assignees, as well as on the participant’s own behalf.

(c) Nothing in the above Release is intended to affect any rights or claims the undersigned may have against a Provider or Care recipient, or against any person or entity other than those Homecare Exchange-related ones described above. (d) If the undersigned is a Provider applicant, this Release does not affect any rights he or she may have either under the PASC-SEIu collective bargaining agreement or against the State of California under Workers Compensation or unemployment Insurance laws. PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE ( 5 ) The undersigned has carefully reviewed and considered each and every one of the terms and conditions of this Agreement, understands them, and has decided voluntarily to agree with them. It is understood that the Homecare Exchange and its affiliates will rely upon this Agreement when granting Homecare Exchange participation and services to the undersigned Homecare Exchange participation.

Signature of Participant

Print Name of Participant

Date

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