IHSS Caregiving Essentials English

IHSS-SB-Banner

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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 San Bernardino Program is a research-based program. We encourage you to do your best to answer all questions honestly and accurately.

In this screening application, you will need to complete five 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.
  1. Screening Questions
  2. Caregiver Information
  3. Consumer Information
  4. Alzheimer's Eligibility Survey
  5. Enrollment/Consent forms
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 Caregiving Essentials (12 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 $1,495. *We expect high demand for this program, so participation will be determined by random lottery.
  • Alzheimer’s Alzheimer’s Disease and Related Dementia (6 weeks): 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 $747.50.
     
  • Emergency & Disaster Readiness (6 weeks): 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 $747.50.
Screening Questions 
You response to these questions will help us identify if you are eligible for the IHSS San Bernardino program.







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

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Your response to these questions will help us identify if you are eligible for the IHSS San Bernardino Program.

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

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Please answer all questions to the best of your ability.



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

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The IHSS Plus Alzheimer's 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 a 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 consumers 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.






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Are you interested in the Caregiver Resiliency Teams or IHSS Basics program? (ONLY SELECT ONE)
1. IHSS Caregiving Essentials (12 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 up to $1,495. *We expect high demand for this program, so participation will be granted by random lottery.
2. Caregiver Resiliency Teams (6 weeks) - Learn caregiving skills specialized for assisting consumers with access and functional needs in preparing for, responding to, and recovering from climate-related and other emergencies. Potential compensation up to $747.50.


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If you do have a Power of Attorney (POA) or Authorized Representative, complete questions 2-4, enter "n/a" for questions 5-7 and continue to question 8.

If you do not have a Power of Attorney (POA) or Authorized Representative, enter "n/a" for questions 2-4 and continue to question 5.

Informed Consent Form:
The Center for Caregiver Advancement is a non-profit training organization whose goal is to train long-term care workers, such as your In-Home Supportive Services (IHSS) caregiver, to improve the quality of care you receive.

CCA is offering the IHSS+ Alzheimer’s and Dementia Training Program for Caregivers (IHSS+ Alzheimer’s), with funding from the California Workforce Development Board.

In addition, we will be evaluating the effectiveness of the program to train IHSS caregivers on skills and core competencies around the role of an IHSS caregiver. To evaluate the program, we are collaborating with the University of California, San Francisco (UCSF), Inland Empire Health Plan (IEHP), and Molina Healthcare.

Why am I being asked to take part in this program?
You are being asked to take part in this program because you are an IEHP or Molina Healthcare member and use IHSS services.

This program is voluntary, and there is no cost to join. You do not have to participate. If you say no, it will not change your IHSS services, health care benefits, or how you get care.

What will happen if I take part in this program?
If you join this program, CCA will ask you to do the following:

Agree to have the IEHP or Molina Healthcare (your health plan) share de-identified data on your health care use and cost, for the evaluation of this program. “De-identified” data means information such as your name, birthdate, and medical number will not be shared or linked to the data. You will be anonymous.

Will information about me be kept private?
We will do our best to make sure your privacy and personal information are protected. However, we cannot guarantee total privacy. Your personal information may be given out if required by law.

If information from this study is published or presented at scientific meetings, your name and other personal information will not be used.   
Photo term:

I hereby authorize the Center for Caregiver Advancement (CCA) to take my photograph for use in CCA newsletters, publications, website, and other marketing materials. I also authorize 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 website and social media 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.
Who can answer my questions about being in this program?
Center for Caregiver Advancement (CCA)
2910 Beverly Boulevard
Los Angeles, California 90057
Email: studentaffairs@advancecaregivers.org

You have a right to get a copy of this form and can request it at any time. You can call CCA any time during the study with questions or concerns.

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.

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Thank you for your interest in applying to CCA’s IHSS Caregiving Essentials 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 Caregiving Essentials training and will be compensated with an hourly wage of $16.50 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 Caregiving Essentials 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 San Bernardino 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. 

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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

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If you do have a Power of Attorney (POA) or Authorized Representative, complete questions 2-4, enter "n/a" for questions 5-7 and continue to question 8.

If you do not have a Power of Attorney (POA) or Authorized Representative, enter "n/a" for questions 2-4 and continue to question 5.
Informed Consent Form:
The Center for Caregiver Advancement is a non-profit training organization whose goal is to train long-term care workers, such as your In-Home Supportive Services (IHSS) caregiver, to improve the quality of care you receive.

CCA is offering the Climate Resiliency Training (CRT) Program for Caregivers, with funding from the California Workforce Development Board’s High Road Training Partnership.

In addition, we will be evaluating the effectiveness of the program to train IHSS caregivers on skills and core competencies around the role of an IHSS caregiver. To evaluate the program, we are collaborating with the University of California, San Francisco (UCSF), Inland Empire Health Plan (IEHP), and Molina Healthcare.

Why am I being asked to take part in this program?
You are being asked to take part in this program because you are an IEHP or Molina Healthcare member and use IHSS services.

This program is voluntary, and there is no cost to join. You do not have to participate. If you say no, it will not change your IHSS services, health care benefits, or how you get care.

What will happen if I take part in this program?
If you join this program, CCA will ask you to do the following:

Agree to have the IEHP or Molina Healthcare (your health plan) share de-identified data on your health care use and cost, for the evaluation of this program. “De-identified” data means information such as your name, birthdate, and medical number will not be shared or linked to the data. You will be anonymous.

Will information about me be kept private?
We will do our best to make sure your privacy and personal information are protected. However, we cannot guarantee total privacy. Your personal information may be given out if required by law.

If information from this study is published or presented at scientific meetings, your name and other personal information will not be used.

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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
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


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