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Registry Provider Application Form

All applicants to the Public Authority Registry will be required to undergo a Department of Justice Criminal Background Investigation to determine if the applicant has ever been convicted of certain violations of the Penal Code. Applicants who do not “clear” the DOJ check will not be listed on the Registry. The cost for fingerprinting is the applicant’s responsibility (the cost is approximately $70).

Note: An incomplete application will delay processing

Personal Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City ZIP Code
Home Phone*
Cell Phone*
Social Security Number*
Birthdate*
Month
Day
Year
Gender*
- Male
- Female
- Prefer Not to Answer
Email*
Enter Email Confirm Email

Desired Work Schedule
Mornings*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Afternoons*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Evenings*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Overnight*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Can you work?*
- Holidays
- 1-2 Hour Shifts
Work hours desired per week?*
Preferred Geographic Area
Central County*
- Alamo
- Clayton
- Concord
- Danville
- Lafayette
- Martinez
- Moraga
- Orinda
- Pacheco
- Pleasant Hill
- San Ramon
- Walnut Creek
West County*
- Crockett
- El Cerrito
- El Sobrante
- Hercules
- Kensington
- Pinole
- Port Costa
- Richmond
- Rodeo
- San Pablo
Far East*
- Bethel Island
- Brentwood
- Byron
- Discovery Bay
- Knightsen
- Oakley
East County*
- Antioch
- Bay Point
- Pittsburg

Tell us about you
Do you smoke?*
- Yes
- No
Will you work for a smoker?*
- Yes
- No
Form of transportation*
- Car
- Bus
Live in position?*
- Yes
- No
Read/ Write English?*
- Yes
- No
Client Preference*
- Male
- Female
- No Preference
Will you use your car?*
- Yes
- No
Will you drive client car?*
- Yes
- No
Will you work with pets?*
- Yes
- No
On Call Work?*
- Yes
- No
Which type of pets will you work with?*
- Select All
- Cats
- Dogs
- Birds
- Other
IHSS Authorized Tasks
Check the tasks you are willing to do and have experience with*
- Select All
- Domestic Services
- Meal Preparation
- Meal Clean Up
- Laundry
- Shopping for Food
- Other Shopping Errands
- Respiration
- Bowel & Bladder Care
- Feeding
- Routine Bed Baths
- Dressing
- Menstrual Care
- Ambulation
- Transfer
- Bathing, Oral Hygiene and Grooming
- Rubbing Skin and Repositioning
- Care and Assistance with Prosthesis
- Accompaniment to Medical Appointments
- Accompaniment to Alternative Resources
- Heavy Cleaning
- Protective Supervision
- Teaching and Demonstration
- Para-Medical Services
Specialized Tasks
Willing to do/ Experience with*
- Select All
- Diapers
- Hoyer Lift
- Injections
- Wound Care
- Transferring
- Lifting (0-50 lbs.)
- Lifting (50-100 lbs.)
- Lifting (100+ lbs.)
Preferred Clients
Willing to work/ Experience with*
- Select All
- Men
- Children
- Elderly
- Blind or Visually Impaired
- Hearing Impaired
- Dementia
- Alzheimer’s
- Autism
- Developmental Disabilities
- Paraplegia / Quadriplegia

Language
Choose the language(s) you are fluent in*
- American Sign
- Arabic
- Cantonese
- English
- Farsi
- French
- German
- Italian
- Japanese
- Korean
- Mandarin
- Portuguese
- Russian
- Spanish
- Tagalog
- Vietnamese
- Guajarati
- Hindi
- Punjabi
- Other
Other Language
Other information
Are you willing to submit to random drug test?*
- Yes
- No
How did you hear about us?*
Licenses, Certificates and Trainings
*
- First Aid
- CNA
- CNHA
- CPR
- HHA
- Other
First Aid Expiration
MM slash DD slash YYYY
CNA Expiration
MM slash DD slash YYYY
CNHA Expiration
MM slash DD slash YYYY
CPR Expiration
MM slash DD slash YYYY
HHA Expiration
MM slash DD slash YYYY
Other Certificates or Licenses*
List any training you have had related to In-Home Care:*

Work Experience
How many years of experience providing In-Home care do you have?*
Explain your experience providing in-Home care*
Are you now or have you ever been employed by (IHSS) In-Home Supportive Services?*
- Yes
- No

Work References
Please list three work references that show a continuous and consistent employment history of at least six months each. Make sure to provide names and valid phone numbers of people we can reach and talk to concerning your work.

Please do not list family members as your references
Work Reference 1
Employer or Client Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Supervisor Name*
First Last
Ok to contact*
- Yes
- No

Work Reference 2
Employer or Client Name
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Supervisor Name
First Last
Ok to contact
- Yes
- No

Work Reference 3
Employer or Client Name
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Supervisor Name
First Last
Ok to contact
- Yes
- No

Personal References
Personal Reference 1
Name*
First Last
Phone*
How do you know?*
How Long?
Years*
Months*

Personal Reference 2
Name
First Last
Phone
How do you know?
Months
How Long?
Years

The following questions are Optional (not required). The information will be kept confidential and used only by staff for statistical purposes and to improve opportunities for care providers.
Do you have health Insurance?
- Medi-Cal
- None
Ethnicity:
- African American
- Asian-Pacific Islands
- Caucasian
- Native American
- Latino
- Other
Other Ethnicity

Consent*
I certify that the information on this application is true.
I understand that any false information may eliminate me from consideration. I understand that being accepted to the Contra Costa IHSS Public Authority Registry means my name may be included on lists given to persons who are seeking assistance in their homes.

I understand that the information on this application may also be shared with prospective employers. I also understand that my employer is not Contra Costa In-Home Services Public Authority (IHSS). The IHSS client is my employer. I understand that I am responsible for paying the fees associated with the Criminal Background Investigation (CBI).

I further understand that passing CBI does not guarantee employment. I also understand that the Public Authority DOES NOT guarantee employment. The Public Authority is a referral service for consumers and providers; it is not an employment agency.
Signature
Name*
First Last
Date*
MM slash DD slash YYYY

500 Ellinwood Way, Suite 110 • Pleasant Hill, CA 94523
(800) 333-1081 or (925) 363-6690

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