Host Home Provider Application Question Title * 1. Address Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. Date of birth Date / Time Date Question Title * 3. social security number Question Title * 4. Education High School College Majors/Degree Dates of Attendance Question Title * 5. Work History Employer Dates of Employment Job Title Address Phone Supervisor Name Reason for Leaving May We Contact This Person? Question Title * 6. Work History Employer Dates of Employment Job Title Address Phone Supervisor Name Reason for Leaving May We Contact This Person? Question Title * 7. Work History Employer Dates of Employment Job Title Address Phone Supervisor Name Reason for Leaving May We Contact This Person? Question Title * 8. References Name Relationship Phone Email Question Title * 9. References Name Relationship Phone Email Question Title * 10. References Name Relationship Phone Email Question Title * 11. Are you a citizen of the United States? Yes No Question Title * 12. If not a citizen, are you able to submit proof of your ability to work in the United States legally? Yes No Question Title * 13. Are you currently or have you ever contracted as a Host Home Provider for Adult Foster Care or Child Foster Care? Yes No Question Title * 14. If a consumer or child has lived in your home in the past, please provide the following information: Placement agency, age, gender, length of stay, & reason for move Question Title * 15. Current Consumer(s) living in your home now: Placement Agency, Start Date, Age, & Gender. Question Title * 16. Have you ever been investigated for Mistreatment, Abuse, Neglect, or Exploitation (MANE) allegations? If yes, please explain: Question Title * 17. Has a consumer ever been removed from your home? If yes, please explain: Question Title * 18. Have you or any member of your family ever been arrested for violations of any law other than minor traffic violations? If yes, please explain: Question Title * 19. Have you or any member of your family/household ever been convicted of any crime, felony, child abuse, or an unlawful sexual offense? If yes, please explain: give name, dates, & final outcome. Question Title * 20. Job Specific Information:Why are you interested in providing Host Home services? Question Title * 21. List skills you possess that would make you a successful Host Home Provider: Question Title * 22. List other obligations you plan to continue during your contract (job, family commitments, etc.): Question Title * 23. Host Home Provision is an around-the-clock endeavor. List your plans to get necessary respite, time off, and how you will be taking care of yourself: Question Title * 24. Is there anything else you would like to tell us about yourself or your circumstances? Question Title * 25. List any specialized training, apprenticeship, skills and extra-curricular activities: Question Title * 26. What would you do? You accept a consumer into your home that has a psychiatric diagnosis of Impulse Control Disorder and you have three young children in the home. Something sets the consumer's behavior off one evening and the consumer throws his own television in his room. How do you handle the situation? Question Title * 27. Applicant Statement: I certify that answers herein are true and complete. I authorize investigation of all statements contained in this questionnaire as may be necessary in arriving at a contractual decision. I understand that I will bear any costs of conducting an investigation into my criminal background, driving record, TB testing, screening for household members, and any other investigation deemed necessary by TLC. I will submit a check for the cost of initial screenings (other states or jurisdictions) will be deducted from my first payment from TLC. I may receive a copy of any reports for which I have been paid I certify that I am not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal Department or agency. I hereby understand and acknowledge that, unless otherwise defined by applicable law, that TLC may terminate that contract at any time. It is further understood that any contract may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of TLC. I understand that any false or misleading information given in this questionnaire or interview(s) may result in contract termination. I also understand that I am required to abide by all rules and regulation of TLC. I have received, read, and understand the following documents: Host Home Provider Required Qualifications and Information & General Requirement. Question Title * 28. Applicant Signature (electronic) Question Title * 29. date Date Date Question Title * 30. Home Profile Host Home Provider Name Phone Number Address Date Question Title * 31. If known, which person(s) are you interested in serving? Question Title * 32. Select the following special needs that you would consider supporting: 24-hour supervision/care Poor/nonexistent self-help skills (24-hour care needs) Mild to moderate medical needs Severe medical needs Seizure disorder Non-ambulatory/wheel chair (Your home must be able to be modified to become wheelchair accessible: exterior door with ramp installed, wide doorways, grab bars, etc.) Partial-ambulatory/walker Mild to moderate behavioral challenges Severe behavioral challenges Person labeled as sex-offender No access to children Blind Deaf Severe communication challenges Question Title * 33. Select the following gender/age/groups that you would be interested in serving? Male Female Young adults 18-30 years old Adults 30-50 years old Older Adults 50+ years old Question Title * 34. Which service are you able to provide? Full-time consumer Respite Respite in addition to a full-time consumer Willing to serve more than two individuals Drive consumers to appointments Consumer have own bathroom (not a requirement) Home wheelchair accessible Question Title * 35. Which of the following would you be able to accept from a consumer in your home? Smoking Pets Question Title * 36. Do you specialize in any specific populations? Question Title * 37. List of people living in your home. Please include individuals in services currently in your home. Please provide the following: Name, Relationship, Age, & Gender. Question Title * 38. List of frequent visitors to your home. Include part-time custody, grandchildren, nieces/nephews, or relatives/friends. Please provide the following: Name, Relationship, Age, & Gender Question Title * 39. Do you work outside of the home? Yes No Question Title * 40. If yes, please provide place of employment, phone number, days, & hours Question Title * 41. Do you have auto insurance? Yes No Question Title * 42. Vehicle Year/Make/Model Question Title * 43. Are smokers in the home? Yes No Question Title * 44. If yes, where do they smoke? Question Title * 45. List any pets in the home. Include type. Question Title * 46. Are there any places within a block of your house that children tend to visit (school, daycare center, park, fast food restaurant with playground, etc.) Please describe: Question Title * 47. Tell us about your home. House Style: Ranch Bi-level Tri-level Apartment Other Question Title * 48. Do you: Own Rent Question Title * 49. If you rent, when is your lease up? Question Title * 50. Do you have homeowners insurance? (If no you will need to get it; We will need a copy) Yes No Question Title * 51. Entrances into the home: List all entrances into the home, how many steps at each entrance, is entrance covered with porch/patio/garage, and if each entrance has a ramp installed. (Regulations require one foot of ramp for each inch of height, so a door that is 12 inches off the ground requires 12 feet of ramp.) Question Title * 52. Inside home, on main level, how many stairs to walk up/down to their room? 0-5 steps 5-10 steps 10+ steps Question Title * 53. Steps to Bathroom 0-5 steps 5-10 steps 10+ steps Question Title * 54. How many extra bedrooms are in your home? Question Title * 55. How many bathrooms? Question Title * 56. Do you have a computer you are comfortable using? Question Title * 57. To have a successful placement, there must be a good match between client and provider. The more we know about you, the easier it will be to find a client who would fit well with your lifestyle. Certain behaviors or needs may seem unimportant, but they may have a very dramatic impact on your household activities. Please take your time and consider your answers carefully. Describe your experience working with people with intellectual and/or developmental disabilities. Question Title * 58. Why are you interested in living with someone with intellectual and/or developmental disabilities? Question Title * 59. Describe your typical daily routine. (ex: 7am wake up, 9am kids to school, 6pm dinner time, etc.) Question Title * 60. Describe your strengths and weaknesses: Question Title * 61. Is there anything you are uncomfortable doing? Question Title * 62. Is there anything you are uncomfortable doing? Question Title * 63. Do you have any limitations on transportation or availability? (ex. Day program, social events, personal activities, etc.) Question Title * 64. List your interests/hobbies: Question Title * 65. Additional comments: Question Title * 66. TLC Connections Motor Vehicle & Criminal History CheckPersonal Information: First Name Middle Name Last Name Maiden Name/Other Names Used Date Last Used Email address Social Security Number Date of Birth Sex Drivers License Number State Question Title * 67. All addresses for the last SEVEN years: (List addresses beginning with the most recent)Please include street address, City, State, zip code, county, and dates at this residence: Question Title * 68. Authorization to Release Information and RecordsI understand that TLC will use CBI, to obtain one or more consumer reports and/or investigative consumer reports (“Report”) as part of the hiring or acceptance process. I also understand that if hired or accepted, to the extent permitted by law, TLC may obtain further Reports from outside sources so as to update, renew or extend my employment or contract. I authorize all persons who may have information relevant to this investigation to disclose it to TLC and/or their agent. I release and agree to hold harmless all persons providing such information to TLS, its officers, directors, employees and agents from liability on account of such disclosure. I also release and discharge TLC and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand TLC’s investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to TLC, the following information and/or copies of documents from my military service record: DD214, service record, and any disciplinary records.This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if TLC makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify TLC within five business days of my receipt of the Report that I am challenging the accuracy of such information with TLC. I hereby consent to this investigation and authorize TLC to procure a Report on my background. In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security number and the other information and fully understand that all employment decisions are based on legitimate non-discriminatory reasons. Additionally, I make this authorization to be valid for as long as I am an applicant, employee, or contractor with TLC.By signing below, I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, and any related state summary of rights. Yes No Question Title * 69. Signature Question Title * 70. Date Date / Time Date Question Title * 71. TLC Statement of ConfidentialityIt is the nature of our program that there is a constant flow of personal, confidential information pertaining to the people receiving services at TLC. This information needs to be passed to providers so that they can be better equipped to serve that individual. With this knowledge, we have a great responsibility to respect and maintain confidentiality about these personal matters. Information should be shared only with people who are directly involved with the person receiving services. This includes the Interdisciplinary Team, health care professionals, and the day program employees serving this person. To share the information with others may violate confidentiality. For those providers who are working on an internship or education, and may wish to use their experiences in this work as part of a curriculum for a college degree must approve this with administrators and: 1. Use an alias or made up name for the client2. NEVER disclose addresses, phone numbers, or family member’s names3. ALWAYS avoid using a person’s full name in any situation outside the immediatecircle of providers. People with developmental disabilities may not have the skill or intellectual capacity to defend themselves if they do not agree with or believe what is said about them. They cannot rely on providers to defend them since they, too, may be incorrect or biased about the information they are giving. It is a very complicated issue, so please be sensitive to anything that can undermine hard-earned dignity for the people receiving services at TLC. I have read, understand, and have had any questions regarding the above information answered. Signature Date Submit