Provider Application for Registry instructions




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Michigan Department of Community Health

Provider Application for Registry
INSTRUCTIONS

Please fill out the application as completely and as neatly as possible. Be sure to sign and date your completed application. Completed applications should be mailed to:


Home Help Registry

PO Box 1482

Okemos, MI 48805

If you have any questions about the application or the provider registry, please call the registry hotline at 1-800-979-4662.



Personal Information - Print your full name (last, first, middle), date of birth, address and other information as available.
Other Relevant Information - Fill in all areas that apply to you.
Training and Certification - If you have completed the trainings listed in this section check "Yes" or "No" for any of the listed trainings. If YES, provide the expiration date of the certification if you know your completion date.
Languages Spoken - Check the languages that you feel comfortable speaking on the job. If a language is not listed, then add it under "Other."
Driving and Access to a Car - You only need to fill in the section if you are both able and willing to drive either your car or your employer’s car while on the job.
Work History - Provide information about your most recent work history if any.
Personal References - Provide contact information for at least two people who know you well. Do not list family members.
Work Preferences – This section is used to determine the types of work you are willing and able to do and the variety of people you wish to work with to provide services. Check all that apply. If you have experience working with certain types of people or in doing any of the listed tasks, check the "Experienced" box.
Schedule Preferences - This section is used to help match the work hours you want with the needs of potential clients. Be as accurate and as complete as possible. If you do not provide available times it could result in a lack of referrals. But not providing available times that you are able to work may prevent you from receiving referrals.
Criminal Background Check – Provide information on any criminal convictions. Please note that a "Yes" answer, even a felony conviction, does not necessarily make you ineligible to be placed on the registry.

Be sure to sign and date your application.

AUTHORITY: P.A. 280 of 1939, as amended.

COMPLETION: Required.



PENALTY: Application may not be approved.

The Michigan Department of Community Health is an equal opportunity employer, services and programs provider.




Name

     

     

     

   /    /     




Last

First

MI

Date of Birth (MM/DD/YYYY)




Residence Address:

     

City:

     

ZIP:

     

(Street or P.O. Box)

















Mailing Address:

     

City

     

ZIP

     

(If different from above)



















County of Residence:

     

Gender:  Male  Female







Gender will be used only when a consumer requests a provider of the same gender to provide personal care.




Home Phone:

(     )      

Emergency Phone:

(     )      













Cell Phone:

(     )      

Email Address:

     













OTHER RELEVANT INFORMATION
Are you currently providing Home Help through the Department of Human Services (DHS)?  Yes  No

If yes, for whom?  Relative  Non­Relative
Do you require any accommodation?  Yes  No If yes, please describe:

     
group 203Do you smoke?  Yes  No If yes, will you smoke only outside at work?  Yes  No


Will you work for consumers who smoke?  Yes  No
Would you be willing to work in a home with:

Cats?  Yes  No Dogs? Yes  No Other       No


Could you work for someone with fragrance sensitivities?  Yes  No
group 201Please list any allergies or sensitivities that would prevent you from working in someone's home:

     
TRAINING AND CERTIFICATION


Please check if you have had recent training in this area and can provide proof of training, such as certificates.

Certified Training Completed Training Expiration Date

First Aid  Yes  No      

CPR (cardiopulmonary resuscitation)  Yes  No      

CNA (certified nursing assistant)  Yes  No      

CMH (Community Mental Health)  Yes  No      

Other Home Help/Home Care relevant training, skills or experience? Please list:

     
Are there any skills for which you would like to see training offered? Please list:

     
LANGUAGES SPOKEN Check all the languages you speak well enough to provide care.


 American Sign  Arabic  English Hmong

 Spanish  Vietnamese Other      


group 26What one language do you speak best (including English)?      

DRIVING AND ACCESS TO A CAR (Check Yes or No. A car isn't necessary for many jobs.)
Are you willing to use your car on the job?  Yes  No Yes, provide Drivers License and Insurance Company.

Are you willing to drive a consumer's car?  Yes  No Yes, provide Drivers License and Insurance Company.




Valid Drivers License Number and State:

     

Name of Insurance Company:

     




What counties are you willing to work in?

     










How many miles are you willing to drive or travel for work one way?

     


group 199WORK HISTORY
Please list any HOME HELP/HOME CARE job(s) that you have had lasting 30 days or more in the last five years that we may call as references. Begin with your most recent work. If you do not have HOME HELP/HOME CARE work references, list any other work. We must reach three references, preferably for current or previous employment, volunteer work, or from a school you have recently attended. If you do not have three work or school references, provide us two personal references.


Employer or Consumer:      
Address:     

Phone #      
Best times to call:      

Your Job Title:      

Permission to call:  Yes  No

Supervisor’s/Consumer’s Name (if different from above)

     


Period of employment:

     

     


From (month/yr)

to(month/yr)

Reason for leaving:      

For Office Use Only:  Positive HH/HC reference  Other positive work reference Unable to contact

Verify?  Yes  No



Employer or Consumer:      
Address:     

Phone #      
Best times to call:      

Your Job Title:      

Permission to call:  Yes  No

Supervisor’s/Consumer’s Name (if different from above)

     


Period of employment:

     

     


From (month/yr)

to(month/yr)

Reason for leaving:      

For Office Use Only:  Positive HH/HC reference  Other positive work reference Unable to contact

Verify?  Yes  No



Employer or Consumer:      
Address:     

Phone #      
Best times to call:      

Your Job Title:      

Permission to call:  Yes  No

Supervisor’s/Consumer’s Name (if different from above)

     


Period of employment:

     

     


From (month/yr)

to(month/yr)

Reason for leaving:      

For Office Use Only:  Positive HH/HC reference  Other positive work reference Unable to contact

Verify?  Yes  No



PERSONAL REFERENCES

List two people you know personally whom we can contact as references. Do not list family members.

Name:

     


How do you know this person and for how long?      

Home phone #:     

Work phone #:     



Office: Check if positive reference 




Name:

     


How do you know this person and for how long?      

Home phone #:     

Work phone #:     



Office: Check if positive reference 


WORK PREFERENCES
Please check boxes indicating if you are experienced in or willing to assist in any of the following areas. We cannot guarantee consumers calling you will match all your preferences. We encourage you to consider performing all tasks and serving all consumers.


Work with persons who are: Yes Maybe No Experienced

Personal care including: Yes Maybe Yes Experienced

Men    

Women    

Children    

Adults (18 - 62)    

Elderly (65 plus)    

Terminally ill    

Developmentally Disabled    

Mentally ill    

Memory impaired    

Hearing impaired    

Vision impaired    

Multiply impaired    



Helping with medicine    

Lifting/transferring    

Mobility Assistance    

Feeding    

Bathing    

Dressing    

Grooming    

Toileting, diapers, bed

pans, etc.    

Toileting, catheters/

colostomy bags    





Domestic tasks including: Yes Maybe No Experienced







Meal Preparation & clean-up    

Housework    

Shopping/errands (no car required)    

Laundry    







SCHEDULE PREFERENCES
Are you willing to work:  Routine Care  Holidays  Backup Care  Emergency on­call

Check all the days and times you are available to work weekly:

 All Mornings (6­12)  Mon  Tue  Wed  Thu  Fri  Sat Sun

 All Afternoons 12­6)  Mon  Tue  Wed  Thu  Fri  Sat Sun

 All Evenings (6­12)  Mon  Tue  Wed  Thu  Fri  Sat Sun

 All Midnights (12­6)  Mon  Tue  Wed  Thu  Fri  Sat Sun



Most consumers need part­time providers. You can accept more than one part­time job if you prefer a full­time schedule.
What are the FEWEST hours per week you would be willing to work for one individual consumer?

 0­5 hours per week  6­10 hours per week  11­25 hours per week  26+ hours per week



What is the GREATEST number of hours you would be willing to work for an individual consumer?

 0­5 hours per week  6­10 hours per week  11­25 hours per week  26+ hours per week

Please check whether you want short­term or long­term jobs.

 No Preference  Short-term (Less than 3 months)  Long-term (More than 3 months)

Are you willing to work for more than one consumer?  Yes  No


Employer or Consumer: Address:

Phone #
Best times to call:

Your Job Title:

Permission to call:  Yes No

Supervisor’s/Consumer’s Name (if different from above)

Period of employment:

From to (month/yr) (month/yr)



Reason for leaving:

For Office Use Only:

Positive HH/HC reference

Other positive work reference

Unable to contact



Attempts to call:

1)

2)



3) Follow­Up:

Reference Notes:




Employer or Consumer: Address:

Phone #
Best times to call:

Your Job Title:

Permission to call:  Yes No

Supervisor’s/Consumer’s Name (if different from above)

Period of employment:

From to (month/yr) (month/yr)



Reason for leaving:

For Office Use Only:

Positive HH/HC reference

Other positive work reference

Unable to contact



Attempts to call:

1)

2)



3) Follow­Up:

Reference Notes:



CRIMINAL BACKGROUND CHECK
Have you been convicted of a felony?  Yes  No (A "yes" answer does not automatically disqualify you from being on the Registry. If yes, list the type of felony for all convictions, the date of conviction, as well as the State and County: Use additional paper if more space is needed..


Felony:

     

Sentence:

     

Conviction Date:

     



















Date of Sentence Completion

     

State:




County:



Name and phone numbers of your parole/probation officers we can contact as references:

     
Have you been convicted of a misdemeanor?  Yes  No

Misdemeanor:

     

Sentence:

     

Conviction Date:

     



















Date of Sentence Completion

     

State:




County:



I certify that I am at least 18 years of age and all information on this form is true to the best of my knowledge. I understand that any omission or misrepresentation of information on this form may disqualify me from being listed on the registry. I give the MDCH or its designee permission to conduct a criminal background check. I will report any changes in my criminal history status that occur after this date. I give the MDCH or its designee permission to share my criminal history and other relevant information in my file with individual consumers who are looking for providers.


I understand that I am filling out this application:


  • to possibly list my name on the registry but the application is no guarantee of employment;

  • that a consumer must agree to select me for employment; and

  • that the MDCH is not responsible in any way for finding employment for me with a consumer.


     

Signature Date




AUTHORITY: P.A. 280 of 1939, as amended.

COMPLETION: Required.



PENALTY: Application may not be approved.

The Michigan Department of Community Health is an equal opportunity employer, services and programs provider.




DCH-1421 (12/13) Page


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