Home Care Worker Interest Response Form

Attachment D2

- Home care worker Interest Response Form

Card stock with a self addressed stamped envelope included

• Yes, I am a homecare worker and would like to participate in the Homecare Worker Safety Training program. Please sign here:

______________________________

Please ask your primary consumer (client) to sign here:

• Yes, I am an IHSS consumer and I understand my homecare worker will participate in the Homecare Worker Safety Training program.

_________________________________

□ Mark if signing as the legal guardian or representative of the consumer

Form approved:

OMB No. 0920-XXXX

Print your first and last name:

____________________________________________

Print your consumer’s (client’s) first name:

_____________________________________________

Your telephone numbers:

Home _________________Cell ___________________

Best days to reach you (mark all that are good):

 Monday  Tuesday  Wednesday  Thursday  Friday  Saturday

 Sunday

Best times to reach you (mark all that are good):

 Between 9 AM-12 Noon  Between 12 noon-6 PM  Between 6 PM-9 PM

I would like to participate in a program in:  English  Spanish  Cantonese

Exp. Date __XX/XX/20XX

Exp. Date __XX/XX/20XX

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintain the data needed, and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).