Address:

City:

State:

Zip:

County:

Area Code + Phone Number:

Your Email address:

Do you want to work: Full-Time Part-Time

Please indicate the hours each day that you can work in the morning, afternoon, or evening periods (for example, 8:00 am to 12:00 noon on Mondays). Indicate for all the days you are available and willing to work:

Are you available to work in a back-up capacity (filling in for a regular Personal Assistant)? : Yes No

Are you willing to work any holidays?: Yes No
If YES, which holidays?

Were you 18 years of age or older on your last birthday?: Yes No

Have you ever been convicted of a serious offense (other than a minor traffic violation) after your 18th birthday,
or have you ever forfeited bond in a criminal proceeding?: Yes No

Are you willing to undergo a criminal records and child abuse check as part of this application process?:
Yes No

REFERENCE #1 NAME:

TELEPHONE NUMBER :

REFERENCE #2 NAME:

TELEPHONE NUMBER :

The answers given in this application are true and complete to the best on my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not a contract of employment.

The Applicant’s signature (typed name) on the line below acknowledges that you have been provided this information and have read the qualifications for the employment standards for provider participation as a Personal Assistant in the CSPPPD and Waiver Programs.

Because of the need for protect the health and welfare of the Consumer, the Pennsylvania CSPPPD has established the following standards for the employment of Personal Assistants in the Program:

MINIMUM QUALIFICATIONS FOR EMPLOYMENT AS A PERSONAL ASSISTANT IN THE CSPPPD AND MEDICAID HOME AND COMMUNITY BASED WAIVER PROGRAM.

1. Be 18 years of age or older;
2. Have the required skills to perform Personal Assistance services as specified in the Consumer’s Service Plan;
3. Possess basic math, reading, and writing skills;
4. Possess a valid Social Security number;
5. Be willing to submit to a criminal records check, child abuse check; and
6. Demonstrate the capability to perform health maintenance activities required by the Consumer and/or specified in the Consumer’s Personal Support Plan, or be willing to receive training in performance of health maintenance activity.

Applicant Signature: (type name): Required

Date: Required

Applicants are considered for all positions without regard to race, color, religion, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or disability.