Apply to Become a Provider

General Information

IP Enrollment & Background Check

Have you completed the Individual Provider (IP) enrollment process at IPAC (Independent Provider Assistance Center) at 77 Otis Street?

Have you cleared the Background Check through the California Department of Justice?


Who referred you to the Public Authority?

Languages Spoken

Please check all the languages you speak:

Driving & Access to a Car

Do you rely on public transportation to get to jobs?

Are you willing to use your car on the job?

Are you willing to drive a consumer's car?

* If yes, you must have a current driver's license and auto insurance. IHSS does not pay for transportation services; gas, mileage, maintenance, etc.

Training & Certification

Please check if you have recently completed any of these care provider trainings:

Completion Date:

Completion Date:

Expiration Date:

Name(s) of Certification:

Work Preferences

Please check boxes indicating all your preferences. We cannot guarantee that consumers service needs will match all your preferences. We encourage you to consider performing all tasks and serving all consumers:

Client Type:

Willing

Experienced

Adults

Men

Women

Couples

Children

Seniors (65 years and older)

Physically Disabled

Developmentally Disabled

Psychologically Disabled

Infectious Disease

Palliative Care

IHSS Consumers

Domestic Tasks:

Willing

Domestic Services

Preparation of Meals

Meal Clean Up

Laundry

Shopping for Food

Other Shopping and Errands

Heavy Cleaning

Accompaniment to Medical Appt.

Accompaniment to Alternate Resources

Yard Hazard Clean-Up

Protective Supervision

Teaching & Demonstration for Independent Living

Personal Tasks:

Willing

Experienced

Respiration

Bowel & Bladder Care

Toileting (Assist with Toilet)

Diaper Changes

Feeding

Routine Bed Baths

Dressing

Menstrual Care

Ambulation

Moving In / Out of Bed

Bathing, Oral Hygiene, Grooming

Personal Tasks:

Willing

Experienced

Rubbing Skin, Repositioning

Care & Assistance with Prosthetics

Set Up, Remind Meds

Catheter / Colostomy Bag

Exercise

Hoyer Lift

Lifting/Transferring

Memory Loss

Vital Signs

Other Relevant Information

Do you smoke? (Must not smoke indoors.)

Will you work for consumers who smoke?

Do you have an allergy that would affect your ability to work in a home with? (Check all that applies.)

Are you willing to provide IP services in the event of a disaster?

Schedule Preferences

Most consumers need part-time workers.
You can accept more than one part-time job if you prefer a full-time schedule.

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

Please check whether you want short-term and/or long-term jobs. (You may answer both options.)

Are you willing to work on:


Check all the days and times you are available to work weekly:

Mornings

Afternoons

Evenings

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Geographic Area

Please check off all the locations you would be willing to work. If you are willing to travel to many areas, you may be referred to more jobs:

Work History

List three verifiable work references (home care experience preferred) within the past five years for jobs lasting more than 60 days. If three work references are not available, you must submit at least one job reference or volunteer work experience plus two personal references who are not relatives.

Permission to Call:

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

to

Permission to Call:

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

to

Permission to Call:

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

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Personal References

Please do not list family members (sisters, nieces, grandparents, etc).

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:

Acknowledgement & Consent: