SELF DIRECTED ATTENDANT CARE

FORMS

MEMBER CHECKLIST

The following are key activities that must be completed for Self Directed Attendant Care (SDAC) participation. The member is responsible for completing each of these activities.

Mark off once completed
‡	Received and reviewed the Self Directed Attendant Care “Is It Right for You”
brochure

‡	Case manager completed an initial assessment

‡	Reviewed Member Roles, Rights and Responsibilities with case manager

‡	Received and reviewed the Self Directed Attendant Care Manual

‡	Filled out the Self Directed Attendant Care Agreement

‡	Completed the Training Needs Checklist for Members and received desired training

‡	Worked with case manager to develop an Initial Care Plan and Backup Plan

‡	Contacted Fiscal Employer Agent and received all necessary paperwork

‡	Filled out and sent all paperwork back to the Fiscal Employer Agent

‡	Recruited and hired a qualified Attendant Care Worker (ACW)

‡	Informed ACW of all requirements of the position, including certifications, training, etc.

‡	Got all necessary paperwork for the ACW from the Fiscal Employer Agent and made sure all paperwork was filed out and returned in a timely manner

‡	Provided the ACW with an outline of duties and the ACW Roles, Rights and
Responsibilities

‡	Signed the Self Directed Attendant Care Member/Attendant Care Worker Work
Agreement and had the ACW sign it also

‡	Assessed the training needs of the ACW and arranged for training if needed

‡	Provided orientation to the ACW, including mandatory training of Universal
Precautions and HIPAA, and other special considerations

‡	Scheduled skilled care training by a registered nurse with the case manager if
ACW will do skilled nursing tasks.

‡	Called the case manager to report the start of services from the ACW within 14 days of the service starting

ONGOING RESPONSIBILITIES WITH THE FISCAL EMPLOYER AGENT

Mark off once completed
‡	Update ACW’s CPR and First Aid certifications

‡	Turn in ACW’s timesheets on time each time

‡	Report any changes in the ACW’s duties

‡	Report any demographic changes of member or ACW

‡	Report any ACW terminations or hiring of new ACWs ONGOING RESPONSIBILTIES WITH THE CASE MANAGER Mark off once completed
‡	Report any change in needs

‡	Report any hospitalizations

‡	Report any problems with ACW not providing services

ONGOING RESPONSIBILITES (GENERAL)

Mark off once completed
‡	Review monthly reports from the Fiscal Employer Agent

‡	Complete Member Satisfaction Surveys at six months and 12 months, and annually thereafter

Self Directed Attendant Care Agreement

I,                                                          , choose to participate in the Self Directed Attendant Care (SDAC) service option.  I understand that I will be in charge of actively managing my own health including the following:

Initial

1.	I have received my Self Directed Attendant Care Manual.  I agree to read it thoroughly and ask my case manager about any questions I may have.

2.	I have read and agree to the Member Roles, Rights and Responsibilities of the Self
Directed Attendant Care service option.

3.  I  will  inform  my  case  manager  if  I  need  assistance  with  any  concerns  and/or dissatisfactions with services received.

 		4.	I  will  contact  the  Fiscal/Employer  Agent  at  phone  number 	
within  	days of enrolling in the Self Directed Attendant Care service option.

5.	I will make sure that my attendant care worker does not work more hours than authorized by my case manager.    If I feel that additional hours of service would be beneficial to my health, I will contact my case manager and ask for a reevaluation.

6.	I agree that I will provide training on privacy and confidentiality of member’s health information (HIPAA – Health Insurance Portability and Accountability Act)  to my attendant care worker or ask my case manager to authorize HIPAA training from another party.

7.	I agree that if my attendant care worker is doing skilled care for me, that I will have that care assessed and trained by a registered nurse before the attendant care worker does this skilled care.

8.	I agree that I will provide Universal Precautions training to my attendant care worker or ask my case manager to authorize Universal Precautions training from another party.

9.	I have read and understand the Letting Your Attendant Worker Go section of the SDAC Manual.

I understand that additional training is available for my attendant care worker and/or me if I feel it is necessary.  I understand that I also have the option to receive traditional attendant care services through an agency if I no longer wish to participate in Self-Directed Attendant Care.  I understand that if I do not meet the above requirements, my Case Manager may discontinue my Self Directed Attendant Care service and enroll me in traditional agency-based services.

Case Manager Signature	Date

RATING YOUR PRIORITIES

The purpose of this questionnaire is self-discovery. Use the numbers to indicate how important the following
qualities are to you as you think about
what you are looking for in an
Attendant Care Worker.	1 = Essential

2 = Very Important

3 = Somewhat Important

4 = Not Important

5 = Not Sure	
1. Patience		
2. Neatness		
3. Ability to follow a schedule		
4. Flexibility on the job		
5. Personal appearance		
6. Calm personality		
7. Religious or spiritual beliefs		
8. Honesty and trustworthiness		
9. Empathy-able to feel for others		
10. Morality-has good moral character		
11. Good communication skills		
12. Sense of humor		
13. Punctuality-able to be on time		
14. Positive attitude		
15. Being a responsible worker		
16. Willing to learn		
17. Respect for others		

	WHEN	FREQUENCY	

TASKS	
MORNING	
AFTERNOON	
EVENING	
NIGHT	
MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	
DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	
A. BATHING		
1. Shower																
2. Bath																
3. Bed Bath																
4. Sponge Bath																
5. Other																

B. TOILETING	

1. Bed pan																

2. Commode																

3. Toilet																

4. Urinal																

5. Leg Bag																
6. Incontinence Care																
C. HAIRCARE	
1. Washing hair																
2. Setting hair																
3. Brushing, combing, styling hair																
D. FACE and BODY	
1. Ear care																
2. Nail care																
3. Shaving-face or body hair																
4. Washing face and hands																
5. Soaking feet																
6. Make-up																
7. Lotion/deodorant																
8. Menstrual care																
9. Other																

I. PERSONAL CARE

WHAT DO I NEED?

	WHEN	FREQUENCY	
TASKS	
MORNING	
AFTERNOON	
EVENING	
NIGHT	
MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	
DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	

																
E. DENTAL CARE	
1. Brushing teeth																
2. Flossing teeth																
3. Mouthwash																
4. Denture care																
5. Other																
F. DRESSING and UNDRESSING	
1. Complete assistance																
2. Partial assistance																
G. MEDICAL AIDS	
1. Prosthetics																
2. Orthotics																
3. Support hose																
4. Assistive devices																
5. Hearing aids																
6. Glasses																

All tasks listed can change at any time to best fit the member’s needs. There may also be new tasks needed in the future. This list is to be used as a guide only, not as a set description of attendant duties.	
SPECIAL INSTRUCTIONS:	

	

I. PERSONAL CARE

WHAT DO I NEED?

II. HOUSEHOLD

WHAT DO I NEED?

	WHEN	FREQUENCY	

TASKS	
MORNING	
AFTERNOON	
EVENING	
NIGHT	
MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	
DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	

A. Laundry	

1. Sorting clothes																

2. Washing																

3. Drying																

4. Ironing																

5. Fold clothes																

6. Put clothes away																

B. Shopping	

1. Grocery																

2. Prescriptions																

C. Housekeeping	

1. Making/changing beds																

2. Sweeping																

3. Mopping floors																

4. Vacuuming																

5. Dusting																

6. Cleaning toilet																

7. Cleaning tub and sink																

8. Emptying trash																

10. Wheelchair cleaning																

D. Miscellaneous	
1. Getting mail																
2. Writing checks																
3. Feeding pets																
4. Walking pets																
5. Other																

All tasks listed can change at any time to best fit the member’s needs. There may also be new tasks needed in the future. This list is to be used as a guide only, not as a set description of attendant duties.

SPECIAL INSTRUCTIONS:

III. NUTRITION

WHAT DO I NEED?

	WHEN	FREQUENCY	

TASKS	
MORNING	
AFTERNOON	
EVENING	NIGHT	MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	

A. Meal Preparation	

1. Preparing foods																

2. Set-up (cutting up, mixing, etc.)																

3. Cooking																

4. Serving																

5. Storing and putting food away																

6. Cleaning up																

B. Eating Meals	

1. Breakfast																

2. Lunch																

3. Dinner																

4. Snacks																

C. Special Diets	

1. Low fat																

2. Low cholesterol																

3. Low sodium																

4. Diabetic																

5. Other																

D. Kitchen Chores	

1. Washing dishes																

2. Cleaning oven/stove																
3. Wiping counters																
4. Defrosting/cleaning refrigerator																
5. Empty dishwasher, put away dishes																

All tasks listed can change at any time to best fit the member’s needs. There may also be new tasks needed in the future. This list is to be used as a guide only, not as a set description of attendant duties.

SPECIAL INSTRUCTIONS:

IV. MOBILITY/SAFETY

WHAT DO I NEED?

	WHEN	FREQUENCY	

TASKS	
MORNING	
AFTERNOON	
EVENING	
NIGHT	
MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	
DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	
A. Exercise	
1. Range of Motion exercises																
2. Walking																
3. Exercises																
B. Positioning	
1. Turning																
2. Bed																
3. Chair																
C. Transfers and Lifts	
1. Wheelchair																
2. Bed																
3. Shower or tub																
4. Toilet																
5. Hoyer Lift																
6. Car																
7. Slide Board																
D. Driving and Escorting	
1. School and/or work*																
2. Medical appointments																
3. Shopping																
4. Arrange transportation																
E. Supervision/Companionship	
																
* K-12: If your Individual Education Plan (IEP) identifies needs to assist with education, the school district is responsible for providing Attendant Care during school hours.	

All tasks listed can change at any time to best fit the member’s needs. There may also be new tasks needed in the future. This list is to be used as a guide only, not as a set description of attendant duties.

SPECIAL INSTRUCTIONS:

	WHEN	FREQUENCY	

TASKS	
MORNING	
AFTERNOON	
EVENING	
NIGHT	
MONDAY	
TUESDAY	
WEDNESDAY	
THURSDAY	
FRIDAY	
SATURDAY	
SUNDAY	
DAILY	
WEEKLY	
TWICE A WEEK	
MONTHLY	
A. Bowel Care		
1. Suppositories																
2. Enemas																
3. Manual Evacuation																
4. Digital Stimulation																
5. Other																
B.  Other Skilled Tasks		
1. Bladder Catheterization (non- indwelling) that does not require a sterile procedure
2. Wound Care (non-sterile)

3. Glucose Monitoring
4. Glucagon as directed by the health care provider
5. Subcutaneous Insulin Injection

6. Sliding scale dosing for insulin
7. Permanent gastrostomy tube feeding
8. Other Special Skilled Care
service (must be pre-approved by AHCCCS and the Arizona State Board of Nursing):

List:																
IMPORANT:  All tasks listed in this section require that a registered nurse visit the member and attendant care worker  to  assess,  educate  and  train  the  member  and  attendant  care  worker  regarding  the  specific  skilled
service(s)  that  the  member  requires.	The  registered  nurse  must  determine  that  the  attendant  care worker
understands how and demonstrates the skills to perform the processes or procedures required to provide the specific skilled service BEFORE the attendant care worker can start to do those tasks	
SPECIAL INSTRUCTIONS:	

	

I. SKILLED CARE

WHAT DO I NEED?

TRAINING NEEDS CHECKLIST For Members
You  will  use  many different kinds  of  skills  while participating in  Self  Directed
Attendant Care.  You are the person who can best decide what kind of training you need.  Your Case Manager will help you set it up.  Below is a list of the skills you will use as a member in Self Directed Attendant Care.  Check the box that best fits your need for training with these skills.

Reading Monthly Reports from the Fiscal Employer Agent (for example, a bank statement)

I NEED A LOT OF TRAINING
Finances

I NEED SOME
TRAINING	NONE

Hiring and Managing an Attendant

Writing a Job Description for Workers

Finding Workers to Provide Care Writing a Job Application Screening Applicants
Interviewing Applicants

Checking references

Evaluating applicants and their skills

Employment Contract or Agreement

Training Workers

Tracking Hours and Time Cards

Communication/Inter-Personal
Relationships

Boundaries and Conflict Resolution

I NEED A
LOT OF	I NEED SOME
TRAINING	TRAINING	NONE	
Maintaining Quality of Service	

Assessing Quality of Services Provided by
Your Workers

Supervising Your Worker

Communicating Information with Your Workers About the Job They are Doing (Positive and Negative)

Firing Workers With Poor Job Performance

Planning for Back-Up Care or Emergency
Care

Understanding Services Available in Your
Community

Asking Others for Help When You Need It	
Safety and Health	

Body Mechanics Universal Precautions Disaster Preparedness
Managing Your Own Health Care	

Date

Date	
Member Signature		
Case Manager		

SELF DIRECTED ATTENDANT CARE APPLICATION FOR EMPLOYMENT

Date:  	

PERSONAL INFORMATION
Legal Name:  	 Street Address:  	

Mailing Address:   	

Apt #:  	

City:  	State:  	Zip:   	  How long at above address:  			
Previous Address:  	How Long?  	

Home Phone: (	)_ 	

Work/Cell Phone:  (	) 	

Salary Expected $  	/ Hour

Who should we notify in case of an emergency?

Name  	

Relationship   	

Home Phone   	

Business Phone   	

Some of the members served through the Self Directed Attendant Care option need to be lifted and transferred to and from a wheelchair, bed, toilet or shower bench.  Light housekeeping is almost always required including changing linens, doing laundry, preparing meals, vacuuming and dusting.  Therefore, applicants for this position may need to perform these functions.  If you have any  lifting,  bending,  stooping,  twisting,  gripping or  other physical limitations that may affect your ability to perform these functions, please describe them below.  Please note that any limitations you describe will not automatically prevent me from hiring you, and I will make reasonable accommodations to help you do this job if you are hired.

I have the following limitations:                                                                                          

Have you ever been convicted of a felony or misdemeanor, including sex related or child/adult abuse-related offenses?
Yes	No	If yes, please explain:  	

Do you have a probation officer?	Yes	No

May we have permission to contact your probation officer?	Yes	No

Name of probation officer:   	

Phone #:  	

Please answer the following questions:

1. What qualities do you have that would make you a successful Attendant Care Worker?

2. Why do you want to work as an Attendant Care Worker?

3. What services do you see yourself providing as an Attendant Care Worker?

EDUCATION & TRAINING

Employer reserves the right to verify education.

High School:  	

Year Graduated/GED  	

College:  	

Location (City/State)  	Year Graduated  	

College:  	

Location (City/State)  	Year Graduated  	

Please describe any other training you have completed:  	

Please indicate any foreign languages spoken fluently:  	

WORK HISTORY
Carefully fill in the information below. Volunteer experience may be substituted if there is no employment history. In order to process your application, you must provide complete names
and phone numbers of your employers. Without this information your application cannot be
processed (please list most recent employment first).

Name of Employer:  	

Supervisor:  	

Address:  	Dates of Employment:  	

City:  	 State:  	

Zip:   	 Telephone:  	

Name of Employer:  	Supervisor:  	

Address:  	Dates of Employment:  	

City:  	

State:  	

Zip:  	Telephone:  	

Name of Employer:  	

Supervisor:  	

Address:  	Dates of Employment:  	

City:  	

State:  	

Zip:  	Telephone:  	

Personal References

Carefully fill out the information below. In order to process your application you must provide the complete names and phone numbers of three personal references. These are people who are not relatives and who you have known at least one year.

Name:  	

Phone Number:  	

Relationship:  	

Length of Acquaintance:  	

Name:  	

Phone Number:  	

Relationship:  	

Length of Acquaintance:  	

Name:  	

Phone Number:  	

Relationship:  	

Length of Acquaintance:  	

I hereby state the above information is correct to the best of my knowledge and authorize investigation and verification of all statements contained in this application. I understand that misrepresentation or omission of facts may render me ineligible for consideration.  I authorize my references to disclose any information about me, including information on employment, and release and hold my references harmless from all liability arising from information disclosed.

SIGNATURE  	

DATE:  	

 	Self Directed Attendant Care Skills Checklist 	

Attendant Care Worker (ACW)                                                                has demonstrated the knowledge and ability to provide safe and appropriate care for member:                                                .

ACW Initials	Member
Initials		
		Universal Precautions (cleaning of equipment, proper disposal of waste, hand washing, and protection from germs spread through the air,
bodily fluids and direct contact) Mandatory Training	
		HIPAA and confidentiality of member information Mandatory
Training	
		Skilled care assessment and training (as applicable for member’s needs) completed by a registered nurse.	
		An understanding of the member’s conditions, which are:	
		An understanding of the member’s wishes regarding advance directives, which are:	
		Appropriate communication and conflict resolution skills	
		Maintaining a clean, safe environment for the member	
		Safe and appropriate bathing and personal hygiene for the member	
		Safe and appropriate assistance with member transfers using the following assistive devices:	
		Safe ACW body positioning and movement during all tasks	
		Other knowledge and/or tasks specific to the member:	

ACW Signature:	 		Date:   		

Member Signature:	
 		
Date:   		

Copy this form for the member, ACW and Fiscal Employer Agent

SELF DIRECTED ATTENDANT CARE MEMBER/ATTENDANT CARE WORKER WORK AGREEMENT

This is a work agreement between  	and
(Employer/Member)
 	, who will be an Attendant Care Worker.
(Employee/Attendant Care Worker)

Attendant Care Worker Start Date:	 	/ 	 / 	

Total Number of Hours Per Week:  	

Pay Rate:  	(subject to change)

WORK SCHEDULE

The Attendant Care Worker’s work schedule will be as follows:

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	

							

Please Initial:

 		I have received a copy of the employer’s task list.  I understand that I will be assisting my employer with those tasks.  If additional tasks arise, I understand that the employer may change my job tasks to better reflect his/her needs.

 		I have received a copy of the Attendant Care Worker Role, Rights and Responsibilities and I
agree to adhere to all of the requirements of the Attendant Care Worker position.

Employee Signature	Date

Employer/Member Signature	Date

cc: Fiscal Employer Agent

EVALUATION FORM

Name:  	

Date:  	

Rate Attendant Care Worker Performance by Checking the Box:

Assigned Task	
Excellent	
Acceptable	Needs
Improvement	
Unacceptable	
1.					
2.					
3.					
4.					
5.					
6.					
7.					
8.					
9.					
10.					

Comments:

Plan:

Attendant Care Worker	Employer

Date:  	

EMERGENCY PHONE NUMBERS AND EMERGENCY PLAN
EMERGENCY PHONE NUMBERS

If there is a medical emergency, immediately call:
911

Medical Providers:

Doctor Name:  	

Phone:  	

Pharmacy Name:  	

Phone:  	

Transportation Service Provider:  	

Phone:   	

Medical Power of Attorney:

Name:  	

Phone:  	

Close Relatives or Friends:

Name:  	

Phone:  	

Name:  	

Phone:  	

Name:  	

Phone:  	

Case Manager:

Name:  	

Phone:  	

Other:

Name:  	

Phone:  	

Name:  	

Phone:  	

EMERGENCY PLAN	Page 2

1.  What to do in case of a fire:  	

2.  What to do in case of a medical emergency:  	

3.  What medications I am allergic to:  	

4.  My medications and medical supplies are located:  	

5.  In case of an emergency, please contact:  	

SELF DIRECTED ATTENDANT CARE REPORTING FORM

Member Name:  	

Phone Number:  	

Member AHCCCS ID (if available):  	

Address:  	

City:  	

State:  	

Zip:  	

Person completing report:  	

Phone #:  	

Date of Concern:  	

Time of Concern:  	

Explain the Concern (include who, what, where, when, how and why) and the Action
Taken:

Have you notified the Case Manager:	Yes	No
CM Name:                                                                     Phone Number:                                                              Date/Time Contacted:                                                     

Please check here if you would like a copy of this report returned to you.

BACKUP ATTENDANT CARE WORKER LIST

BACKUP ATTENDANT CARE WORKERS	

NAME	
PHONE	Hours/Days
Available	
Comments