Calaveras County Provider Registry Application Form Page 3
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LANGUAGES:
PRIMARY LANGUAGE: (Pls. identify)
American Sign
Italian
OTHER
Arabic
Japanese
[Please specify]
________________________________
English
Spanish
French
Tagalog
__________________
German
Do you have any felony criminal convictions?
Have you ever used illegal drugs or alcohol in a work setting?
Yes
No
YES
NO
If “YES”, convicted of: _____________________
If “yes”, please explain: _________________________________
_______________________________________
____________________________________________________
Felony conviction date/s: ___________________
I have had drug and alcohol problems:
_______________________________________
Please explain: _______________________________________
Case disposition: _________________________
____________________________________________________
_______________________________________
Do you give the Registry permission to conduct a background check?
YES
NO
TRAININGS and CERTIFICATIONS
List any training you have had related to care-giving or in-home care:
List any certificates or licenses you possess:
First Aid
Expires: _____/____/_____
CNA
Expires: _____/____/_____
CPR
Expires: _____/____/_____
CHHA
Expires: _____/____/_____
How many years of experience providing in-home care do you have?
REFERENCES
[Provide a minimum of 2 employment, and 1 personal. Do not use relatives, please.]
Employment
1. NAME: ________________________________________________ PHONE #: ______________________________
MAILING ADDRESS: ______________________________________________________________________________
Employment
2. NAME: ________________________________________________ PHONE #: ______________________________
MAILING ADDRESS: ______________________________________________________________________________ _
Personal
1. NAME: ________________________________________________ PHONE #: ______________________________
MAILING ADDRESS: ______________________________________________________________________________
IHSS-PA Provider App. (v7 – 01/07)
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