Form Temp 3000 - In-Home Supportive Services (Ihss) Program Overtime And Workweek Requirements Recipient Declaration Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Case Number : _____________________
3. My provider works more hours for me than my maximum weekly hours in a
workweek without getting approval from the county, causing more overtime hours
in the month than normal; or
4. My provider’s claimed travel time is more than seven hours in a workweek.
• Sometimes I may need my provider to work more than my weekly maximum hours.
I must ask the county for approval to adjust my weekly maximum hours; even if the
county approves my request for an exception, I will need to have my provider work
less hours in the next workweek(s) of the month so that I don’t go over my authorized
monthly hours. The county will send me a notice to let me know whether my exception
request was approved or denied.
• The county will send me a notice when my provider gets a violation. If my provider
gets three violations, he/she will be suspended from providing IHSS for three
months. If he/she gets another violation after being reinstated from the three-month
suspension, he/she will be terminated as a provider for one year.
RECIPIENT ACKNOWLEDGMENT
I understand and agree to follow all of the requirements listed in this form.
RECIPIENT’S SIGNATURE:
DATE:
RECIPIENT’S PRINTED NAME:
DATE:
AUTHORIZED REPRESENTATIVE’S SIGNATURE:
AUTHORIZED REPRESENTATIVE’S PRINTED NAME:
FOR COUNTY USE ONLY
WORKER NAME:
DATE:
TEMP 3000 (1/16)
PAGE 2 OF 2

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