Personal Assistant Candidate Information Request Form

If you are SEEKING a position as a Personal Assistant to provide Home Care related support services to a Consumer participating in a Consumer Directed Personal Assistance Program (CDPAP), please complete the following form.

Note: (to move from field to field please use the "TAB" key)

Personal Assistant Candidate:
Personal Assistant Candidate's Name - Required


Phone ... Best Time

E-mail- Required

Note: An E-mail address is Required to permit Consumer Directed Services
to add you to the data base and to permit you to receive the weekly newsletters and the Consumer job offerings.
Do you authorize Consumer Directed Services to PUBLISH your E-mail address on the Internet?
Yes . . . .No
Note: Your choice not to enter a Yes or No in the above field will be accepted as an indication that you agree to permit Consumer Directed Services to PUBLISH your E-mail address.

Gender Female . . . .Male

Type of Position you are Seeking:
Domestic / Homemaking
Personal Care / Home Health
Other Position - Describe

Have You Worked with a CDPAP Consumer/Surrogate Yes . . . No
If Yes - Can you get a Reference from the Consumer/Surrogate Yes . . . .No
If Yes - Years Employed with the Consumer/Surrogate
Are you Currently Registered with a CDPAP AgencyYes . . . No
If Yes - CDPAP Agency Name(s)

Indicate Your Experience:
Children . . . . Teens . . . . Young Adults . . . . Seniors
Paraplegia . . . . Quadriplegia . . . . Hemiplegia . . . . Amputation
Ventilators . . . . Wheelchairs . . . . Lifters . . . . Other Equipment
Mental Impairments/Alzheimer's Disease . . . . Visual/Auditory Impairments
Special Diets - Describe
Languages - List
Other - Describe

New York State Requirement and Documentations:
If you are seeking employment from a Consumer who is receiving their service authorization from a New York State Medicaid funded Consumer Directed Personal Assistance Program, the Consumer is permitted to consider your employment only if you can pass ALL of the following New York State reviews.
1. You are an adult of at least 18 years of age.
2. The Consumer is not your spouse or (if the Consumer is younger then 21) is not your child.
3. You do not live in the home of the Consumer (unless their service requires it).
4. You are not the Designated Representative (Surrogate) of the Consumer.
5. You do not have any financial control over the Consumer.
6. Your information must pass a Federal and State Government Exclusion List Review.
7 You have a verifiable Social Security number and the qualified documents needed to prove that you are eligible to work in the United States.

Can you pass ALL of the New York State Reviews?
Yes . . . .No

- If No - Describe New York State Review Problem

The State of New York also requires each Personal Care Assistant to complete a Health Assessment BEFORE you begin work.
The Health Assessment includes:
- A basic physical exam - blood pressure, height, weight, etc.
- A TB (Tuberculosis) Screen (PPD) or a chest x-ray if the test is positive or if the test would not be appropriate
- A Measles and Rubella Screen or Vaccine
- A drug test of Urine (forensic toxicology)

Have you had a Health Assessment in the past 12 months?
Yes . . . .No

Do you have or can you get a copy of your recent Health Assessment?
Yes . . . .No

Other Documentation Available:
Proof of Identity . . . . Recommendations

In addition to the above New York State requirements, the municipality in which the Consumer lives may also impose additional health assessments or legal reviews. The Consumer Directed Personal Assistance Program your Consumer chooses will require the completion of a Memorandum of Understanding (Consumer / Personal Care Assistant Agreement) to clarify the employment relationship, and they may require other documents to help them effectively complete their role as the Consumers Fiscal Intermediary.

Indicate Your Certificates / Licenses
Personal Care . . . . Home Health Aid . . . . LPN or PN . . . . RN
Driver's License . . . . Other - Describe

Schedule You are Seeking:
Hours Per Week . . . . Days Per Week . . . . Preferred Start Time
- What days would you like to work.
- Are you willing to work a 24 Hour Sleep-In schedule.

Salary You are Seeking (Enter One):
Per Hour . . or . . Per Day . . or . . Per Week

Other - A short comment about your Qualifications:
(Your Resume and References should be Presented when Interviewed)

When your information is received, it will be included in the weekly Newsletter that is distributed to our list of Consumers and Advocates, and posted on the Consumer Directed Services web site. Your information will also be added to the Consumer Directed Services Database, which will permit us to send you the Newsletter and emails with information from Consumers who are searching for new Personal Assistants.

As a Personal Assistant Candidate, applying for a position with a Consumer (an Independent Person with a Disability or their Representative) please recognize that the Consumer is exclusively responsible for all decisions related to the terms and conditions of your training and employment.

Also, although a few of the Consumers who access the weekly Newsletter can independently finance their own Home Care Services, most of the Consumers participate in a Medicaid Funded program, which establishes the rate of pay and requires the completion of various program and tax documents, and may require the completion of a physical examination.

Finally, please remember that Consumer Directed Services has no role in the process, which may lead to your eventual employment, beyond the distribution of your information to interested parties. Consumer Directed Services urges you to please respect the Consumer, their time and the process, by keeping them informed if you have any difficulty keeping an appointment or if you are fortunate enough to be able to accept an alternative opportunity. The employment process is unpredictable and a little courtesy today may open a new door to an employment opportunity in the future.




Edward Litcher
540 Main Street, Suite B1314, Roosevelt Island, NY 10044
Phone: 718.233.3312
Fax: 718.233.3312