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 $55 - $85).

Note: An incomplete application will delay processing

Printable PDFs

Registry Provider Application

Release of Information Consent

Personal Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City ZIP Code

Home Phone(Required)

Cell Phone

Social Security Number(Required)

Birthdate(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Prefer Not to Answer

Email(Required)

Enter Email Confirm Email

Desired Work Schedule

Time of Day(Required)

Mornings

Afternoons

Evenings

Overnight

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?(Required)

Holidays

1-2 Hour Shifts

Neither

Work hours desired per week?(Required)

Preferred Geographic Area(Required)

Central County

East County

Far East County

West County

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

East County

Antioch

Bay Point

Pittsburg

Far East County

Bethel Island

Brentwood

Byron

Discovery Bay

Knightsen

Oakley

Tell us about you

Do you smoke?(Required)

Yes

Will you work for a smoker?(Required)

Yes

Form of transportation(Required)

Car

Bus

Live in position?(Required)

Yes

Read/ Write English?(Required)

Yes

Client Preference(Required)

Male

Female

No Preference

Will you use your car?(Required)

Yes

Will you drive client car?(Required)

Yes

Will you work with pets?(Required)

Yes

On Call Work?(Required)

Yes

Which type of pets will you work with?

Cats

Dogs

Birds

Other

IHSS Authorized Tasks

Check the tasks you are willing to do and have experience with(Required)

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

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(Required)

Women

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(Required)

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?(Required)

Yes

How did you hear about us?(Required)

Licenses, Certificates and Trainings

Select any Licenses, Certificates and Trainings you hold

First Aid

CNA

CNHA

CPR

HHA

Other

None

First Aid Expiration

MM slash DD slash YYYY

CNHA Expiration

MM slash DD slash YYYY

HHA Expiration

MM slash DD slash YYYY

CNA Expiration

MM slash DD slash YYYY

CPR 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?(Required)

Explain your experience providing in-Home care(Required)

Are you now or have you ever been employed by (IHSS) In-Home Supportive Services?(Required)

Yes

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

Phone

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Ok to contact

Yes

Work Reference 2

Employer or Client Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Supervisor Name

First Last

Ok to contact

Yes

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

Personal References

Please list two names of people who know you personally whom we can contact as character references. Personal References must be different from Work References.

Please do not list family members.

Personal Reference 1

Name(Required)

First Last

Phone(Required)

How do you know?(Required)

How Long?

Years

Months

Personal Reference 2

Name

First Last

Phone

How do you know?

How Long?

Years

Months

Optional Questions

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

Other

Ethnicity:

African American

Asian-Pacific Islands

Caucasian

Native American

Latino

Other

Other Ethnicity

Consent(Required)

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.

Release of Information Consent(Required)

I give permission for the Contra Costa County IHSS Public Authority to obtain information regarding my work history.

I understand this release of information consent is valid for 90 days from the date indicated below.

Name(Required)

First Last

Signature

Date(Required)

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.