English Enrollment Form

CCA Screening Form

CCA is currently offering classes in the following counties: Los Angeles, San Francisco, San Mateo or Santa Clara. Please select your county of residence:

F1. County:

Los AngelesSan FranciscoSan MateoSanta Clara

F2. Email Address

For all other counties, submit an interest form or refer a friend.

Page 1A

IHSS LA CARE Screening

Please fill out this screening application to see if you are eligible for the program. Complete it as soon as possible since the program fills up quickly. Please note that the IHSS LA CARE Program is a research-based program. We encourage you to do your best to answer all questions honestly and accurately.

Please only submit ONE application. Submitting multiple applications will not improve your chances in the lottery. All applications are screened for duplicates and past entries across all languages.

In this screening application, you will need to complete six sections. The application will take about 45 minutes to 1 hour. You can save your answers and return to the application at a later time.

Screening Questions
Caregiver Information
Consumer Information
Enrollment/Consent forms
Training Survey
Schedule Preference

A CCA representative will call you in 5-7 business days after you complete this application. If you’re approved, you can enroll in one of the following programs:

IHSS LA CARE (10 weeks): Learn fundamental caregiving skills essential to becoming a recognized care team member. Training includes personal care, infection control, nutrition and body mechanics, medication adherence, and home safety. Potential compensation of $1,540.00

*We expect high demand for this program, so participation will be determined by random lottery.

Page 2A

LA CARE Screening Questions Your response to these questions will help us identify if you are eligible for the IHSS LA CARE program.

2A1. What is your full name?

2A2. Primary Phone Number

Format: 1234567890

2A3. Do you reside in Los Angeles County?

YesNo

2A4. Are you 18 years old or older?

YesNo

2A5. Do you care for a consumer that resides in Los Angeles county?

YesNo

2A6. Are you currently employed as an IHSS Caregiver?

YesNo

2A7. Is your consumer a member of the LA CARE Health plan?

YesNo

2A8. Do you care for more than one consumer in Los Angeles?

YesNo

2A9. Is your consumer a family member?

YesNo

Page 1B

HRTP HC ADRD/EDR Screening

In this screening application, you will need to complete five sections. The application will take about 45 minutes to 1 hour.

Screening Questions
Alzheimer’s Disease and Related Dementia Survey
Caregiver Information
Consumer Information
Enrollment Terms

A CCA representative will call you in 5-7 business days after you complete this application. If you’re approved, you can enroll in one of the following programs:

Alzheimer’s Disease and Related Dementia (15 hours): Learn caregiving skills for consumers with Alzheimer’s disease and related dementia, including strategies for managing symptoms and common behaviors like sundowning, hallucinations, and wandering. Potential compensation of $770

Emergency & Disaster Readiness (15 hours): Learn caregiving skills for assisting consumers with access and functional needs in preparing for, responding to, and recovering from climate-related and other emergencies. Potential compensation of $770.

Page 2B

HRTP HC ADRD/EDR Screening Questions

2B1. What is your full name?

2B2. Primary Phone Number

Format: 1234567890

2B3. Which county do you reside in?

San Francisco CountySan Mateo CountySanta Clara CountyCounty Not Listed Here

2B4. Are you 18 years old or older?

YesNo

2B5. Are you currently employed as an IHSS Caregiver?

YesNo

2B6. Is your consumer a family member?

YesNo

Page 3

Screening Questions

Your response to these questions will help us identify if you are eligible for the program. In order to enroll in the program, active IHSS employment is required. Please upload a picture or screenshot of your last IHSS paystub.

3.1. Paystub

Page 4

Screening Questions

Your response to these questions will help us identify if you are eligible for the program.

Please make sure the document type and your name are clearly visible.

Please rename your file to your name.

4A1. In order to enroll in to the program your Recipient's current residency in Los Angeles County is required. If your recipient is your child and under 17 years of age, please provide your proof of address. Please select the type of document you will upload as proof of address. (One answer)

California State driver's licenseGovernment issued ID cardLease agreementUtility billMortgage statementInsurance documentGovernment issued letter

4B1. To enroll in the program, you must reside in one of the following counties: San Francisco, San Mateo, or Santa Clara. Please upload a document to prove your address.(One answer)

California State driver's licenseGovernment issued ID cardLease agreementUtility billMortgage statementInsurance documentGovernment issued letter

4.2. Proof of address

Page 5

Caregiver Information

Please answer all questions to the best of your ability.

5.1. Please enter today's date (mm/dd/yy)

5.2. What is your IHSS Provider ID number?

5.3. What is your First Name?

5.4. What is your Middle Name?

5.5. What is your Last Name?

5.6. Date of Birth
Format: MM/DD/YYYY

5.7. Primary Phone Number

Format: 1234567890

5.8. Will you provide your Social Security number?

Declining will not affect your enrollment chances.

Yes I prefer not to share or disclose this information.

5.9. Social Security Number

Format: 123-45-6789

5.10. Address Line 1

Physical address of your home

Format: 1234 Street, Apt 1

5.11. City

5.12. State

5.13.

Zip Code

5.14. Address Line 2

Mailing address such as PO box

If not applicable, leave blank

5.15. How do you describe yourself?
(check one)

5.16. Do you think of yourself as: (check one)

5.17. What is your ethnicity?(check all that apply)

American Indian / Alaska NativeAsian / Asian AmericanBlack / African AmericanHispanic / LatinxMiddle Eastern or North AfricanNative HawaiianPacific IslanderWhite or CaucasianNot Listed HereI do not wish to self identify

5.175 What is your race??(check all that apply) HOLD FOR APPROVAL for Hidden field

5.18. Do you have a disability?

YesNoI do not wish to self identify

5.19. Are you a Veteran?

YesNoI do not wish to self identify

5.20. Employment Status

EmployedUnderemployedNot in labor forceUnemployed

5.22. What is your individual total yearly income before taxes? No ($) symbol

5.23.

What is your household's total yearly income before taxes? (You must list gross income before taxes) No ($) symbol

Individual income cannot be more than the household income.

Income Validation

5.24. How many people live in your household, including you?

5.25. What is your unemployment compensation (UC) status?

ClaimantExhausteeNeither claimant nor exhausteeI do not wish to self-identify

5.26. Long-Term Unemployed

Yes: unemployed ≥ 27 consecutive weeksNo

5.27. Displaced Worker
(i.e., job loss due to layoff or company closure)

YesNo

5.28. Are you currently in school?

Currently in schoolCurrently out of school

5.29. What education have you completed?

I don't have a high school diploma or equivalentI have a high school diploma or equivalentI have some post-secondary education (after high school)I have post-secondary certification (non-degree)I have an AA/AS degreeI have a BA/BS degreeI have a Graduate degree

5.30. Are you an immigrant?

YesNoI do not wish to self identify

5.31. Has your TANF run out (i.e. CalWORKS)?

YesNo

5.32. Will you run out of your TANF within 2 Years?

YesNo

5.33. Are you currently getting TANF?

YesNo

5.34. Are you currently getting CalFRESH (i.e. food stamps)?

YesNo

5.35. Are you currently getting SSI/SSDI?

YesNoNot Applicable

5.36. Do you have Foster Care Youth status?

YesNo

5.37. Are you a Homeless Individual or Runaway Youth?

YesNo

5.38. Have you been in jail?

YesNoI do not wish to disclose

5.39. Are you currently learning English?

YesNo

5.40. Do you have trouble reading and writing?

YesNo

5.41. Are you a single parent?

YesNoI do not wish to self identify

5.42. Are you a Displaced Homemaker?

YesNo

5.43. Are you a Migrant / Seasonal Farmworker?

NoSeasonal Farmworker AdultMigrant Farmworker AdultMigrant / Seasonal Farmworker YouthDependent AdultDependent Youth

5.44. What kind of job do you want?

5.45. What industry do you want to work in?

5.46. How many consumers are you caring for?

5.47. What COUNTRY were you born in? (example: United States, Mexico, and Canada, etc.)

Your response is required for the application to be considered complete. N/A is not valid

5.48. If born outside the US, how many years have you live outside of the US?

If not applicable please enter 0

5.49 AE. Are you a citizen of the United States?

Yes, born in the United StatesYes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern MarianasYes, born abroad but my parents are U.S. citizen(s)Yes, I am a US citizen by naturalizationNo, I am not a US citizenI prefer not to answer

5.50. How did you find out about CCA? Check all that apply

Employer/ConsumerProviderSEIU ULTCW / Local 2015Phone CallHealth Plan/InsuranceHouse VisitCommunity PresentationMediaLetterFriend/Another ConsumerOtherFriend/Another IHSS CaregiverFlyerCommunityPresentationCounty Public Authority

5.51. Which device do you use to go online? Check all that apply:

SmartphoneComputerTabletLaptopDo not have one/Need a device.

5.52 LAC. What language do you prefer taking the class in?

5.53 LAC. Caregiver Other language

5.52AE. What language do you prefer taking the class in?

5.53AE. Caregiver Other language

Page 6

Consumer/ Recipient Information

All questions should be answered by your IHSS recipient/consumer (your client).

6.1. What is today's date (mm/dd/yyyy)

6.2. What is your client's IHSS recipient number? (The recipient number on the IHSS paystub)

6.3. What is your client's First Name?

6.4. What is your client's Middle Name?

6.5. What is your client's Last Name?

6.6. What is your client's date of birth? (mm/dd/yyyy)

6.7. What is your client's age?

6.8. What is your client's Medi-Cal ID number?

6.9. What is your client's preferred phone number?

If your client does not have a phone number, please add yours.

6.10. What is your client's email?

If your client does not have an email, please add yours.

6.11. What health care coverage does your client have?

MedicaidMedicarePrivate/Health Insurance/Health PlanIndian Health ServiceVA Health System (Veterans of Armed Forces)Tricare (Armed Forces)Care 1stCare MoreHealth NetLA CareIEHPMolinaKaiserAlameda AllianceOther

6.12. Other health care coverage

6.13. What is your client's ethnicity?

American IndianAlaska NativeAsian or Asian AmericanBlack or African AmericanHispanic/LatinxNative HawaiianPacific IslanderMiddle EasternNorth AfricanWhite or CaucasianNot listed herePrefer not to answer or do not know

6.14. What is your client's Gender?

FemaleMaleNon-Binary

Page 7B

Alzheimer's Eligibility Survey

The Alzheimer's Disease and related dementia program is interested in training caregivers who care for those with cognitive decline, like Alzheimer's. While your consumer may not be diagnosed with Alzheimer's, they may show signs of cognitive impairment or memory loss. Please answer the following survey to the best of your ability. The following eight questions will ask you to reflect on any changes in your consumer's daily life. Yes means that there has been a change, and No means that there has not been a change. And N/A means you do not know if there has been any change.

Remember, (yes) a change indicates that there has been a change in the last several years caused by cognitive (thinking and memory) problems.

Consumer Name

7B1. Problems with judgment (for example, problems making decisions, bad financial decisions, problems with thinking)

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B2. Less interest in hobbies/activities

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B3. Trouble learning how to use a tool, appliance, or gadget? (e.g., VCR, computer, microwave, remote control)

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B4. Repeats the same things over and over (questions, stories, or statements)

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B5. Forgets correct month or year

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B6. Trouble handling complicated financial affairs (e.g., balancing checkbook, income taxes, paying bills)

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B7. Trouble remembering appointments

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B8. Daily problems with thinking and/or memory

Yes (A Change)No (No Change)Not Applicable (N/A) (I do not know)

7B9. Is your consumer 50 years old or older?

YesNo

7B10. AD8 Results

Page 8B

ADRD Caregiver Enrollment Form

8B1. Today's date

Provider Information

8B2. What is your First Name?

8B3. What is your Middle Name?

8B4. What is your Last Name?

8B5. Date of Birth

8B6. Email

8B7. Address Line 1

8B8. City

8B9. State

8B10. Zip Code

8B11. Full Legal Name

Your response is required for the application to be considered complete. N/A is not valid

8B12. Information Terms:

IHSS caregivers must read, sign and date below:

I hereby attest that the information given above is correct to the best of my knowledge. Confirm #1

I agree to the terms and conditions

8B13. Stipend Terms:

By signing below, you agree to the following terms and conditions:

To participate in the IHSS+ Alzheimer’s Training Program (IHSS+ Alzheimer’s), and to maintain your eligibility in IHSS+ Alzheimer’s to receive a stipend payment of $500 plus $18 per hour in class for a total of $770 for care provided to the IHSS Consumer, you must:

* Be a current caregiver of In Home Supportive Services (“IHSS”) as authorized by the State of California.

* Be approved by CCA to qualify for taking the IHSS+ Alzheimer’s training.

* Complete the 15-hour training course created by CCA.

* The stipend will be distributed after the end of the 6-week training course.

* Complete two surveys: pre-training and post-training surveys

Confirm #2

I agree to the terms and conditions

8B14. Photo Terms:

I hereby authorize the Center for Caregiver Advancement (CCA) to take my photograph for use by CCA for newsletters, publications, website, and other marketing materials. I also authorize The Center for Caregiver Advancement (CCA) to use, reproduce, and/or publish any audio or video content that may pertain to me, including my image, likeness, and/or voice, without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs), or for other related endeavors. This material may also appear on the Corporation's or project sponsor's Internet Web Page and promotional sites such as, but not limited to, CCA’s YouTube page. CCA will only use this for promotional and educational purposes.

This authorization is continuous and may only be withdrawn by my specific rescission.

Confirm #3

I agree to the terms and conditions

8B15. I understand that when I type my name on the signature line it will have the same effect as if I had handwritten my signature in ink with a pen on that line. Signature:

8B16. Provider ID

8B17. ADRD Recruitment Program:

8B18. ADRD Affiliation Index :

Page 8C

EDR Caregiver Enrollment Form

8C1. Today's date

Provider Information

8C2. What is your First Name?

8C3. What is your Middle Name?

8C4. What is your Last Name?

8C5. Date of Birth

8C6. Email

8C7. Address Line 1

8C8. City

8C9. State

8C10. Zip Code

8C11. Information Terms:

IHSS caregivers must read, sign and date below:

I hereby attest that the information given above is correct to the best of my knowledge. Confirm #1

I agree to the terms and conditions

8C12. Stipend Terms:

By signing below, you agree to the following terms and conditions:

To participate in the Emergency Disaster Readiness Training Program ( Emergency Disaster Readiness EDR), and to maintain your eligibility in Emergency Disaster Readiness, to receive a stipend payment of $500 plus $18 per hour in class for a total of $770 for care provided to the IHSS Consumer, you must:

* Be a current caregiver of In Home Supportive Services (“IHSS”) as authorized by the State of California.

* Be approved by CCA to qualify for taking the IHSS+ Alzheimer’s training.

* Complete the 15-hour training course created by CCA.

* The stipend will be distributed after the end of the 6-week training course.

* Complete two surveys: pre-training and post-training surveys

Confirm #2

I agree to the terms and conditions

8C13. Photo Terms:

I hereby authorize the Center for Caregiver Advancement (CCA) to take my photograph for use by CCA for newsletters, publications, website, and other marketing materials. I also authorize The Center for Caregiver Advancement (CCA) to use, reproduce, and/or publish any audio or video content that may pertain to me, including my image, likeness, and/or voice, without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, bro.adcast public service advertising (PSAs), or for other related endeavors. This material may also appear on the Corporation's or project sponsor's Internet Web Page and promotional sites such as, but not limited to, CCA’s YouTube page. CCA will only use this for promotional and educational purposes.

This authorization is continuous and may only be withdrawn by my specific rescission.

Confirm #3

I agree to the terms and conditions

8C14. I understand that when I type my name on the signature line it will have the same effect as if I had handwritten my signature in ink with a pen on that line. Signature:

8C15. Provider ID

8C16. EDR Recruitment Program:

8C17. EDR Affiliation Index :

Page 7A

IHSS LA CARE Provider Consent Form

Thank you for your interest in applying to CCA’s IHSS LA CARE training. To decide who can join the training, we’ll use a random lottery, like picking names out of a hat.

Random Selection: Due to high demand, we cannot accommodate all applicants. To ensure fairness, participants will be randomly selected for the training group or the waiting list.

Neither you nor CCA will have control over which group you are assigned to. It's a bit like a coin toss, with an equal chance of being placed in either group.

Participants in the training group will receive the IHSS LA CARE training and will be compensated with an hourly wage of $18.00 for 30 hours, as well as a $1,000 stipend upon successful course completion.

The waiting list compensation is $75.

To enter the lottery and have a chance to take the IHSS LA CARE course, you must agree to provide consent below.

If you choose to enter the lottery, you will not be able to take other CCA training programs, such as Alzheimer’s Disease and Related Dementia (ADRD) and Emergency Preparedness/Climate Resiliency Teams (CRT) in Los Angeles County for the next two years. This restriction applies even if you are on the waiting list for Caregiving Essentials.

Data Sharing and Confidentiality: CCA may share information about your application, your performance during training, and related data with researchers working with CCA. Researchers may also use information on this application to access official records, such as wage reports, unemployment insurance records, IHSS program records, tax records, and healthcare records. Government agencies already collect this information. Taking part in the study means that researchers are able to use the information for research purposes. The research team will follow strict rules to protect your privacy. Any information you provide is confidential. Findings from research may be published in scientific journals, meetings, or public data sets. However, no one will be able to identify individuals in any of these publications.

Consent: Participation in this study is voluntary. If you decide to withdraw from the evaluation, you may also be able to remove your data from the evaluation. If you choose to leave, or have any questions or concerns about the study, please contact ihss.study@povertyactionlab.org.

Photo Terms: I hereby authorize the Center for Caregiver Advancement (CCA) to take my photograph for use of CCA for newsletter, publications, website, and other marketing materials. I also authorize The Center for Caregiver Advancement (CCA) to use, reproduce, and/or publish any audio or video content that may pertain to me, including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the Corporation's or project sponsor's Internet Web Page and promotional sites such as, but not limited to CCA’s YouTube page. CCA will only use this for promotional and educational purposes.

This authorization is continuous and may only be withdrawn by my specific rescission.

7A1. By clicking “I agree to participate in the research” and typing your name below, you confirm that you have read the consent form, are at least 18 years old, and agree to participate in the research. Please print or save a copy of this page for your records.

I agree to participate in the researchI do NOT agree to participate in the research

7A2. Full Name:

7A3. LAC Recruitment Program:

7A4. LAC Affiliation Index :

Page 8A

LA Care Signature Caregiver ALL PROVIDERS-- PLEASE READ AND SIGN BELOW:

8A1. Today's Date:

Provider Information

8A2. First Name:

8A3. Middle Name:

8A4. Last Name:

8A5. Email:

8A6. Address:

8A7. City:

8A8. State:

8A9. Zip Code:

8A10. Information Terms:

I hereby attest that the information given above is correct to the best of my knowledge. Confirm #1

I agree to the terms and conditions

8A11. Photo Terms:

This authorization is continuous and may only be withdrawn by my specific rescission.

Confirm #2

I agree to the terms and conditions

8A12. Stipend Terms:

By signing below, you agree to the following terms and conditions:

1. To participate in the IHSS+ Provider Training Program (IHSS+), and to maintain your eligibility in IHSS+ to receive a stipend payment of one thousand five hundred and forty dollars ($1,540.00), you must:

a. Be a current provider of In Home Supportive Services (“IHSS”) as authorized by the State of California to a beneficiary who is enrolled in L.A. Care Health Plan in Los Angeles, California as a member.

b. Be approved by the IHSS Consumer to participate in IHSS+.

c. Complete the 10-week training course created by L.A. Care Health Plan and CCA.

This course will train you on new skills and prepare you to take on new roles to:

• Communicate about changes in health or a variety of healthcare issues of the IHSS Consumer

• Monitor changes in health conditions or medication adherence of the IHSS Consumer

• Coach to support overall improved quality of life for the IHSS Consumer (i.e. eating healthy foods, getting exercise)

• Work to help support the IHSS Consumer’s overall care in the home

• Navigate through the healthcare system with the IHSS Consumer

2. If, at any time the IHSS Consumer is no longer enrolled in L.A. Care Health Plan or if the IHSS Consumer removes you as their IHSS Provider your stipend payment shall end immediately.

*Confirm #3:

I agree to the terms and conditions

8A13. I understand that when I type my name on the signature line it will have the same effect as if I had handwritten my signature in ink with a pen on that line. Signature:

8A14. Provider ID

8A15. LAC Recruitment Program:

8A16. LAC Affiliation Index :

Page 9A

IHSS LA CARE Training Baseline Survey

SECTION 1: IHSS AND WORK EXPERIENCE

9A1. Why were you interested in caregiver training?

I want to improve my caregiving skillsI want to receive the financial compensationMy consumer requested I seek trainingMy consumer's care team recommended I seek training (a care team includes licensed professionals such as a doctor, nurse, pharmacist, or social worker)I want to prepare for a career in caregiving or healthcare

9A2. How many total years have you been working as an IHSS caregiver?

Less than a year1 - less than 3 years3 - less than 6 years6 - less than 10 years10 or more years

9A3. How many total years of paid work experience do you have in caregiving?

Less than a year1 - less than 3 years3 - less than 6 years6- less than 10 years10 or more years

9A4. How many total years of experience in caregiving paid and unpaid?

Less than a year1 - less than 3 years3 - less than 6 years6 - less than 10 years10 or more years

9A5. Overall, how satisfied are you with your IHSS job?

Very dissatisfiedDissatisfiedNeither satisfied or dissatisfiedSatisfiedVery satisfied

9A6. I feel I have the skills I need to perform my job well

Strongly disagreeDisagreeNeutralAgreeStrongly agree

9A7. I know I can meet all the needs of the IHSS consumer

Strongly disagreeDisagreeNeutralAgreeStrongly agree

9A8. I have people in my life I feel comfortable asking for help when I need it

Strongly disagreeDisagreeNeutralAgreeStrongly agree

9A9. Why did you become an IHSS caregiver? (Select all that apply)

Someone I know needed careIt is a better job than the one I had beforeI prefer this job because of the flexibilityOther reasons

9A10. Have you received any formal caregiver training prior to this course?

YesNoMaybe

9A11. Have you received a professional healthcare license or certification? (Select all that apply)

Yes, I am a Certified Nurse Assistant (CNA)Yes, I am a Home Health Aide (HHA)Yes, I am a Certified Hemodialysis Technician (CHT)Yes, I have a certification from a different countryYes, I have a certification not listed hereNoDon't know

9A12. Do you have other jobs outside of IHSS currently? (Select only one)

I do not have another jobI have one other jobI have two other jobsI have three or more other jobs

9A13. If you have a main job outside of IHSS; what is your hourly wage?

I do not have another jobLess than $16 per hour$16 - less than $20$20 - less than $25$25 - less than $30$30 or more per hour

9A14. If you have a main job outside of IHSS; what kind of business or industry is it in?

I do not have another jobRetail tradeHealth care and social assistanceFood services and accommodationOther

9A15. If you have a main job outside of IHSS; how many hours did you work at this job last week?

I do not have another jobLess than 10 hours10 - less than 25 hours25 - less than 40 hours40 - less than 65 hours65 or more hours

SECTION 2: CAREGIVING SKILLS AND KNOWLEDGE

For each of the following statements, choose whether it is True or False. If you do not know, select do not know.

10A1. Positive changes in the consumer's health do not need to be documented and shared with the care team.

TRUEFALSEDo not know

10A2. When assisting a consumer to undress, you start on the weaker side of their body.

TRUEFALSEDo not know

10A3. Lifting heavy items using my back, rather than my leg strength, protects me from injury.

TRUEFALSEDo not know

10A4. Sharps (needles, razors, etc.) can be disposed of in a regular trash bin.

TRUEFALSEDo not know

10A5. Incontinence (lacking control of holding urine or bowel movement) may decrease the risk of pressure sores.

TRUEFALSEDo not know

10A6. A simple modified diet for a consumer with high cholesterol includes eating lean meat and steamed vegetables.

TRUEFALSEDo not know

10A7. Preventing falls in the home is one of the best ways to avoid hospitalization.

TRUEFALSEDo not know

10A8. Some medications (including over the counter and herbal supplements) can increase fall risk.

TRUEFALSEDo not know

10A9. To prevent female urinary tract infection, clean between the legs from front to back.

TRUEFALSEDo not know

10A10. As an IHSS caregiver, I may give medication directly to the IHSS consumer.

TRUEFALSEDo not know

10A11. Caregiver burnout can be avoided by using various self-care techniques.

TRUEFALSEDo not know

10A12. Person-centered care includes considering consumer preferences and expressed needs.

TRUEFALSEDo not know

10A13. All bodily fluids are potentially infectious.

TRUEFALSEDo not know

10A14. Wearing masks and increasing spacing/distance are ways to prevent disease from spreading.

TRUEFALSEDo not know

10A15. Caregivers can begin an exercise program for their consumer without consulting the doctor.

TRUEFALSEDo not know

10A16. It is safe to leave food to defrost on the kitchen counter at room temperature.

TRUEFALSEDo not know

10A17. Shortness of breath due to an allergic reaction requires a visit to the emergency room.

TRUEFALSEDo not know

10A18. Self-care is an emergency response plan to stress.

TRUEFALSEDo not know

10A19. Do you know how to access the following resources in your community? (Select all that apply)

Urgent CareMember ServicesNurses Advice LineBehavioral Health Services

SECTION 3: CAREGIVER WELL-BEING

Caregivers are often so concerned with the needs of their IHSS consumers that they may lose sight of their own well-being. Take a moment to read and respond to the following statements.

11A1. During the past week or so I have had trouble keeping my mind on what I was doing

YesNo

11A2. During the past week or so I have felt that I couldn’t leave my IHSS consumer alone

YesNo

11A3. During the past week or so I have had difficulty making decisions

YesNo

11A4. During the past week or so I have felt completely overwhelmed

YesNo

11A5. During the past week or so I have felt useful and needed

YesNo

11A6. During the past week or so I have felt lonely

YesNo

11A7. During the past week or so I have been upset that my IHSS consumer has changed so much from their former self

YesNo

11A8. During the past week or so I have felt a loss of privacy and/or personal time

YesNo

11A9. During the past week or so I have been edgy or irritable

YesNo

11A10. During the past week or so I have had sleep disturbed because of caring for my IHSS consumer

YesNo

11A11. During the past week or so I have had a crying spell(s) (periods of crying or breakdown)

YesNo

11A12. During the past week or so I have felt strained (fatigued or tired) between work and family responsibilities

YesNo

11A13. During the past week or so I have had back pain

YesNo

11A14. During the past week or so I have felt ill (headaches, stomach problems or common cold)

YesNo

1A15. During the past week or so I have been satisfied with the support my family has given me

YesNo

11A16. During the past week or so I have found my IHSS consumer’s living situation to be inconvenient or a barrier to care

YesNo

11A17. On a scale of 1 to 10, with 1 being “not stressful” to 10 being “extremely stressful", please rate your current level of stress

11A18. On a scale of 1 to 10, with 1 being “very healthy” to 10 being “very ill,” please rate your current health compared to what it was this time last year

11A19. Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?

Not at allSeveral daysMore than half the daysNearly every day

11A20. Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Not at allSeveral daysMore than half the daysNearly every day

11A21. Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?

Not at allSeveral daysMore than half the daysNearly every day

11A22. Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?

Not at allSeveral daysMore than half the daysNearly every day

SECTION 4: RELATIONSHIP TO CONSUMER

12A1. Do you live in the same household as the consumer for whom you provide the most care?

YesNo

12A2. What is your relationship to the consumer for whom you provide the most care?

I am their:

Family member or relativeFriend or neighborHomecare worker hired from the IHSS registryOther

12A3. Did you care for your consumer before becoming an IHSS provider?

Yes, as much or more than currently.

Yes, but less than currently.

RarelyNeverI don't know

12A4. In the last year, has the consumer whom you’ve provided the most care needed to go to the emergency room or hospital or had a medical emergency?

YesNo

SECTION 5: YOUR ROLE AS AN IHSS CAREGIVER

13A1. What tasks do you perform for your consumer? Check all relevant categories.

Housework & Meals (cleaning, laundry, preparing meals, grocery shopping)Personal Care Services (dressing, bathing, brushing teeth, bladder care, help with walking, etc.)Paramedical Services (check blood sugar, give injections, other services)Accompanying them to medical appointments or other appointments

13A2. Are there tasks on the list above that you do not perform but that could help your consumer?

YesNo

13A3. If yes, why are you unable to perform these tasks? [Optional] (Select all that apply)

Not authorized by IHSSLack of TrainingLack of hours with consumerOther constraints (financial, lack of transportation)Consumer is not interested in help with those tasksI answered no to the previous question

113A4. Would you consider taking care of someone who is not a family member in the future?

Definitely notProbably notUncertainProbably yesDefinitely yes

13A5. If no, what additional support or changes would you need in order to consider taking care of a non family member in the future?

I am not interested in caring for a non-familyHigher rate of payMore trainingTransportation

13A6. Do you think engaging in caregiver training will impact your desire to care for a non-family consumer?

I am already interested in caring for a non-familyYesNoUnsure

13A7. What additional tasks could help your consumer that you wish you could perform?

Your response is required for the application to be considered complete. N/A is not valid

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IHSS LA CARE Schedule - English Classes

10A1. The IHSS LA CARE class is offered at different days/times. Please select all that work for you.

Tuesdays: 2/10/2026 - 4/28/2026 at 6:00 PM - 9:00 PMWednesdays #1: 2/11/2026 - 4/29/2026 at 10:00 AM - 1:00 PMWednesdays #2: 2/11/2026 - 4/29/2026 at 6:00 PM - 9:00 PMThursdays #1: 2/12/2026 - 4/30/2026 at 9:00 AM - 12:00 PMThursdays #2: 2/12/2026 - 4/30/2026 at 6:00 PM - 9:00 PMSaturdays: 2/14/2026 - 5/2/2026 at 10:00 AM - 1:00 PM

Thank you for your interest.

Unfortunately you do not meeting the requirements for these programs.

We hope that you qualify for other/future programs we may offer.

If you feel like this is a mistake please feel free to contact us at studentaffairs@advancecaregivers.org

Click submit button and wait to receive a message that your form has been submitted

Thank you for signing your consent forms.

The Enrollment Team will be reviewing all documents and will call you in 5-7 business days.

The Enrollment Team will verify which one of our day/times are available for your enrollment and can answer any questions.

Have any enrollment questions? Email us at studentaffairs@advancecaregivers.org

Click submit button and wait to receive a message that your form has been submitted

Term Agreements

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