DHS/DSPD
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Form 2-9EA (CSW)
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES
SELF-ADMINISTERED SERVICES AGREEMENT
Employment Agreement (CSW)
1. PARTIES. This Employment Agreement (referred to hereafter as “Agreement”) is between
(referred to hereafter as “EMPLOYER”).
Name of Person/ Person’s Representative/Person’s Administrator
AND
Employee’s Name (EMPLOYEE):
(Last,
First,
Middle I)
Employee’s Street Address:
City:
State:
ZIP:
Phone Number:
Employee’s SSN #:
2. PURPOSE.
EMPLOYEE has been retained by EMPLOYER to provide services to
(referred to hereafter as “PERSON”).
Name of Person Receiving Services
Services provided to PERSON by EMPLOYEE are to be provided under the direction and
supervision of the EMPLOYER. Identified below are the service(s) that EMPLOYEE may be
authorized and certified to provide at the direction of EMPLOYER. Also listed below are the
current rates of payment for authorized services.
Chore Services (CH1)
$
per ¼ hour
Companion Services (CO1)
$
per ¼ hour
Family Training and Preparation (TF1)
$
per ¼ hour
Homemaker Services (HS1)
$
per ¼ hour
Personal Assistance (PA1)
$
per ¼ hour
Respite Care (RP1)
$
per ¼ hour
EMPLOYEE Initial