中文课程报名表 (Chinese Enrollment Form)

CCA篩選表 (CCA Screening Form)

CCA 目前在以下縣提供課程: 洛杉磯 (Los Angeles), 舊金山 (San Francisco), 聖馬刁 (San Mateo), 聖塔克拉拉 (Santa Clara). 請選擇您居住的縣:

對於所有其他縣, 請提交興趣表或推薦給朋友.

Page 1A

IHSS LAC 篩選

請填寫此份篩選申請表,以確認您是否符合參與該計畫的資格。該計畫名額很快就會額滿,因此請你儘快完成。請注意,IHSS LA CARE 計畫是一項基於研究的計畫。我們鼓勵您盡量誠實且準確地回答所有問題。

請僅提交一份申請表。提交多份申請表並不會增加您在抽籤中被選中的機會。所有申請表都會經過篩選,排除所有語言的重複申請和過往參加的紀錄。

您需要完成四個部分以完成填寫這份篩選申請表。填寫此份申請表約需 45 分鐘至 1 小時。您可以保存您的答案,稍後再返回申請表繼續填寫。

篩選問題
照護人員資訊
照護對象資訊
註冊表/同意書

完成此份申請表的填寫和提交後,CCA 代表將於 5-7 個工作天內撥打電話與您聯絡。若您獲核准,可註冊參加以下任一計畫:

IHSS LA CARE(10 週):學習成為得到認可的照護團隊成員必備的基礎照護技能。培訓內容包括個人護理、感染控制、營養和人體力學、藥物依從性和家庭安全。可能獲得 1540.00 美元補償金

*我們預計本計畫會有很多申請者,因此參與資格將以隨機抽籤方式決定。


Page 2A

LA CARE 篩選問題 您對以下問題的答案將協助我們確認您是否符合 IHSS LA CARE 計畫的資格。








Page 1B

HRTP HC ADRD/EDR 篩選

在此份篩選申請表中,您需要完成五個部分。填寫此份申請表約需 45 分鐘至 1 小時
  1. 篩選問題

  2. 阿爾茲海默氏症和相關失智症調查

  3. 照護人員資訊

  4. 用戶資訊

  5. 注冊條款

此份申請表填寫完成後,CCA 代表將於 5-7 個工作天內撥打電話與您聯絡。若您獲核准,可註冊參加以下任一計畫:


  • 阿爾茲海默氏症和相關失智症(15 小時):學習針對患有阿爾茲海默氏症和相關失智症的用戶的照護技能,包括應對相應症狀及常見行為(如日落症候、幻覺與遊蕩)的策略。可能獲得 770 美元補償金
  • 緊急情況與災難應變準備(15 小時):學習相應照護技能,用於協助有使用和功能需求的用戶針對氣候相關及其他緊急情況進行準備、應對及恢復。可能獲得 770 美元補償金。

Page 2B

篩選問題




Page 3

篩選問題

您對以下問題的答案將協助我們確認您是否符合. 為註冊參加該計畫,您必須處於有效的 IHSS 受僱狀態‌。請上傳您最近一份 IHSS 工資單的照片或電子版截圖。

Page 4

篩選問題

您對以下問題的答案將協助我們確認您是否符合。

‌請確保文件類別與您的姓名清晰可辨.
請以你的名字重新命名文件。


Page 5

照護人員資訊 請盡力回答所有問題。


個人收入不能超過家庭收入


Page 6

用戶/照護對象資訊

所有問題均由您的 IHSS 用戶/照護對象(您的客戶)來回答


Page 7B

阿爾茲海默氏症計畫資格調查
該阿爾茲海默氏症和相關失智症計畫旨在對認知能力下降者(如阿爾茲海默氏症)的照護人員進行培訓。即使您的用戶尚未確診阿爾茲海默氏症,若出現認知障礙或記憶喪失跡象,仍可參與本調查。 請盡力回答以下調查問題。以下八個問題將要求您回想用戶日常生活中的任何變化。是表示發生了變化,否表示沒有發生變化。N/A(不適用)表示您不知道是否發生了變化
請記住,(是)有變化表示最近幾年有變化,而且變化是由於認知(思維和記憶)問題引起的。






Page 8B

ADRD 照護人員注冊表
服務提供者資訊

Page 8C

EDR 照護人員注冊表
服務提供者資訊

Page 7A

IHSS LA CARE Provider Consent Form - HIDDEN UNTIL RCT STARTS

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. 

Page 8A

LA Care 照護人員簽名 所有照護人員-- 請閱讀並在下面簽名:
照護人員資訊

Page 9A

SECTION 1: IHSS AND WORK EXPERIENCE
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.
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.
SECTION 4: RELATIONSHIP TO CONSUMER
SECTION 5: YOUR ROLE AS AN IHSS CAREGIVER

Page 14A

IHSS LA CARE 課程時間安排
感謝您的關注。
很遺憾,您不符合這些項目的要求。

我們希望您有資格參加我們可能提供的其他/未來計劃。
如果您認為這是一個錯誤,請隨時透過 studentaffairs@advancecaregivers.org 與我們聯繫

點擊提交按鈕並等待收到表單已提交的訊息

感謝您簽署同意書。


外展團隊將審查所有文件並在 5-7 個工作日内與您聯絡。


外展團隊將核對適合您報名注冊的時段(日期/時間),並解答所有相關疑問。


關於報名注冊是否有任何疑問? 請發電子郵件至 studentaffairs@advancecaregivers.org


點擊提交按鈕並等待收到表單已提交的訊息.


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