Calaveras County Provider Registry Application Form (Page 4 of 4) in pdf

Page 4

Criminal Background Checks on IHSS Providers - -

Current law states, In-Home Supportive Services (“IHSS”)

Consumers (the employer of IHSS Providers) and the Public Authority:

Have the legal right to conduct Department of Justice (DOJ) criminal background checks on current Providers

or Providers they are considering hiring.

May decide not to hire or retain Providers who refuse to complete background checks.

May decide not to hire or retain Providers based on the results of background checks.

Must protect the confidentiality of the results from DOJ background checks.

I understand that fingerprinting may be done through the Public Authority for the purpose of a DOJ criminal background

check. I further understand the results may be shared with my potential employer, the IHSS Consumer.

I am willing to be fingerprinted for a DOJ background check:

YES

Initials: _____

Further, regarding this application to participate on the Provider-Consumer Registry:

I certify under penalty of perjury that all the information provided in this application and its related process is

true. I understand that any false information may eliminate me from eligibility for participation on the Provider-

Consumer Registry.

I understand that my name may be placed on a list to be given to persons who are seeking assistance in their

homes, without further notice.

I understand the Public Authority retains the exclusive right to list, refer with or without comment, suspend, or

remove an individual Provider from the Registry.

I understand that Registry staff will conduct a background check on me using publicly available resources.

I understand that the information on this questionnaire may also be shared with prospective employers and their

advocates without further notice.

I understand completing this application and being listed on the Registry does not guarantee me employment.

I understand that my employer is not Calaveras County In-Home Supportive Services (“IHSS”) or the Calaveras

County IHSS Public Authority. The IHSS Consumer is my employer.

I further understand that an IHSS Consumer-Employer retains the exclusive right to hire, supervise, and

terminate my employment with or without cause.

I understand that I may by written request, ask that my name be deleted from participation on the Provider-

Consumer Registry.

Signature:

_________________________________

Date:

_______________________

Print Name:

_________________________________

----------------------------------------------------------------------------------------------------------------------------------------------------------------

Remember to call the Registry to update your availability, phone number, and address whenever there is a

change. If you do not, you will be made inactive and your name will not be referred to IHSS Consumers.

IHSS-PA Provider App. (v.7 – 01/07)

Page 4 of 4

Calaveras County Provider Registry Application Form Page 4

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