ultcw_homecarexchangeapp_provider_english

8/7/2019 ultcw_homecarexchangeapp_provider_english

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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

Homecare excHangeapplication Form For providers

ULTCW

NAME

EMAIL

ZIP

ADDRESS

CITY STATE

CELL PHONE HOME PHONE

SOCIAL SECuRITY # CA ID / DRIVERS LICENSE #

GENDER: ____FEMALE ____MALE DATE OF BIRTH (OPTIONAL) ______/______/______

Feeding

Grooming

Heavy Cleaning

Ironing

Laundry

Medication Dispensation

Menstrual Care

Prosthetic Assistance

Protective Supervision

Repositioning and Skin Care

Service Animals

Shopping

Wheelchair Assistance

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


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Any experience and/or training in the following? Please check all that apply.

Alzheimers Disease

Arthritis

Asthma

Cancer

Certied Nurses 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? Yes No

Are you willing to work for a care recipient with a dog? Yes No

Are you willing to work for a care recipient with a cat? Yes No

Are you willing to work at a home where there is a smoker? Yes No

Are you willing to comply with a no-smoking rule at your care recipients home? Yes No

How many hours are you currently working? per month.

How many additional IHSS hours do you wish to work? per month.

Would you be willing to work for a non-IHSS (private pay) client? Yes No

Do you have a car that can be used for work? Yes No

Mental / Emotional Disability

Multiple Sclerosis

Paralysis

Parkinsons Disease

Range of Motion

Respiration Assistance

Registered Nurse

Seizures

Special Diet

Spinal Bida

Spinal Cord Injury

Stroke

Thalamic Brain Injury

Visual Impairment

Vital Signs

Wound Care


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MON. TES. WED. THRS. FRI. SAT. SN.

times oF availaBilitY

Check the days and times when you might be willing to schedule services by entering a YES

or NO where applicable.

MORNING

AFTERNOON

EVENING

OVERNIGHT

LIVE-IN

ON-CALL

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 Middle School

College Major

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?


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Homecare emploYment HistorY

Please list below each care recipient you have worked for within the last three years.

Name of care recipient

Date: From To

Reason for ending service

Phone number of care recipient (if available)

(If care recipient not available)Name and phone number of recipient family member:


Date: From To





Date: From To





Date: From To





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Date: From 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 disqualication

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 drivers license or identication card

3) Photocopy of your social security card

4) Photocopy of a check stub with a deduction for union dues

FOR OFFICE USE ONLY

Participants Right, Responsibilities and Release Form signed and received? Yes No

Date Processed By


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Employment History checked by Date

References checked by Date

please read careFullY

PARTICIPANTS 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 afliates and agents from any liability.

Homecare Exchange

1. Nature of Homecare Exchange Services: SEI, The nited Long-Term Care Workers nion,

Provides this nion 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. HomecareExchange 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 verication 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 prole. Any Care recipient

and applicant Provider therefore must use their own judgment and make their own decisions

regarding one anothers skills, character and compatibility, and as to how well they may meet each

others 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 recipients

employee. In accordance with the law and County DPSS requirements and guidelines, the Carerecipient has sole authority to hire, assign hours and duties, direct the work, supervise, evaluate,

and choose whether to continue or terminate the Providers 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 )


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Receipt and se 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 condential 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 condential procedures. Any disputes concerningany such uses or related decisions are to be determined by the Homecare Exchange Management

Committee. The decisions of the Homecare Exchange Management Committee are nal 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.

PARTICIPANTS RIGHTS, RESPONSIBILITIES AND RELEASE ( 4 )

PARTICIPANTS 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 SEI LTCW, the County of Los Angeles,

afliated agencies such as those furnishing emergency/respite services to Care recipients, the

individual ofcers, governing board members, agents, employees, representatives, advisers,

insurers and volunteers of the Homecare Exchange and of such related and afliated 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 participants

personal representatives, family, heirs, dependents, community property and assignees, as well as

on the participants own behalf.


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(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-SEI collective bargaining agreement or against the State of

California under Workers Compensation or nemployment Insurance laws.

PARTICIPANTS 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 afliates 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

Documents

ultcw_homecarexchangeapp_provider_english