Calaveras County Provider Registry Application Form Page 2
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GEORGRAPHIC PREFERENCE:
Altaville
Dorrington
Mountain Ranch
Valley Springs
Angels Camp
Douglas Flat
Murphys
Wallace
Arnold
Glencoe
Paloma
West Point
Avery
Hathaway Pines
Railroad Flat
Wilseyville
Burson
Jenny Lind
Rancho Calaveras
OTHER
Camp Connell
Milton
San Andreas
[Outlying County areas, for
Campo Seco
Mokelumne Hill
Vallecito
example: Sheep Ranch,
Copperopolis
Tamarack, White Pines, etc.]
TYPE of WORK DESIRED:
Accompaniment to Alternative Resources
(taking Consumer to & from appointments where they receive services in lieu of IHSS)
Accompaniment to Medical Resources
Ambulation
(assisting with walking, or with moving from place to place)
Bathing/Oral Hygiene/Grooming
(includes “stand-by assistance”)
Bowel/Bladder Care
(external appliances only)
Care & Assistance w/ Prosthesis; Medication set-up
(assistance w/ medications)
Domestic Services
(Clean floors, wash kitchen counters, stoves, refrigerators, bathroom; store food, supplies; take out garbage; dust,
pick-up; bring in fuel; change or make bed; and miscellaneous.)
Dressing
Feeding
Heavy Cleaning*
(authorized 1x/mo. only)
Meal Clean-up
Meal Preparation
Menstrual Care
Moving In/Out of Bed
Other Shopping & Errands
Protective Supervision
(keeping Consumers safe from harming themselves or others)
Respiration
Routine Bed-baths
Routine Laundry
(Includes routine ironing)
Rubbing Skin; Re-positioning; etc.
Shopping for Food
WILLING to WORK WITH:
Adults
Alzheimers
Children
Developmental Disability
Elderly
Infectious Diseases
Memory Problems
Men
Mental Health Issues
Parkinsons
Quadriplegics
Terminal Illness
Women
YOUR ETHNICITY: (Optional)
African-American
Caucasian
Native American
Asian/Pacific Islander
Latino
OTHER
IHSS-PA Provider App. (v.7 – 01/07)
Page 2 of 4
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