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    SOC332L

    Uploaded by

    Keri Hamner

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SOC332L

    Uploaded by

    Keri Hamner
    88 views4 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    88 views4 pages

    SOC332L

    Uploaded by

    Keri Hamner

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    California Health & Human Services Agency California Department of Social Services

    IN-HOME SUPPORTIVE SERVICES


    RECIPIENT/EMPLOYER RESPONSIBILITY CHECKLIST
    I, ______________________________ , HAVE BEEN INFORMED
    BY MY SOCIAL WORKER THAT AS A RECIPIENT/EMPLOYER, I
    AM RESPONSIBLE FOR THE ACTIVITIES LISTED BELOW.

    1. Provide required documentation to my Social Worker


    to determine continued eligibility and need for services.
    Information to report includes, but is not limited to, changes to
    my income, household composition, marital status, property
    ownership, phone number, and time I am away from my home.

    2. Find, hire, train, supervise, and fire the provider I employ.

    3. Comply with laws and regulations relating to wages/hours/


    working conditions and hiring of persons under age 18.

    NOTE: Refer to Industrial Welfare Commission (IWC)


    Order Number 15 regarding wages/hours/working conditions
    obtainable from the State Department of Industrial Relations,
    Division of Labor Standards and Enforcement listed in the
    telephone book. Additional information regarding the hiring of
    minors may be obtained by contacting your local school district.

    4. Verify that my provider legally resides in the United States. My


    provider and I will complete Form I-9. I will retain the I-9 for at
    least three (3) years or one (1) year after employment ends,
    which ever is longer. I will protect the provider’s confidential
    information, such as his/her social security number, address,
    and phone number.

    SOC 332L (1/19) Page 1 of 4


    California Health & Human Services Agency California Department of Social Services

    5. Ensure standards of compensation, work scheduling, and


    working conditions for my provider.

    6. Inform my Social Worker of any future change in my


    provider(s), including:
    __ Name
    __ Address
    __ Telephone Number
    __ Relationship to me, if any
    __ Hours to be worked and services to be performed by each
    provider

    7. Inform my provider that the gross hourly rate of pay is


    $______________, and that Social Security and State Disability
    Insurance taxes are deducted from the provider’s wages.

    8. Inform my provider that he/she may request that Federal


    and/or State income taxes be deducted from his/her wages.
    Instruct the provider to submit Form W-4 (for federal income
    tax withholding) and/or Form DE 4 (for state income tax
    withholding).

    9. Inform my provider that he/she is covered by Workers’


    Compensation, State Unemployment Insurance benefits, and
    State Disability Insurance benefits.

    10. Inform my provider that he/she will receive an information sheet


    that will state my authorized services and the authorized time
    given to perform those services. Payment will not be made for
    any services not authorized.

    SOC 332L (1/19) Page 2 of 4


    California Health & Human Services Agency California Department of Social Services

    11. Pay my share of cost, if any.

    12. Ensure the total hours reported by each provider for services
    provided to me while working for the IHSS program does not
    exceed more than my total weekly authorized hours in one
    workweek, unless I receive county approval for the increase.

    13. Verify and sign my provider’s timesheet for each pay period,
    showing the correct day(s) and the total number of hours
    worked. I understand I can be prosecuted under Federal
    and State laws for reporting false information or concealing
    information.

    14. Ensure my provider signed his/her timesheet.

    15. Advise my provider to mail his/her signed timesheet to the


    appropriate address at the end of each pay period.

    Recipient’ Signature Date

    Printed Name

    SOC 332L (1/19) Page 3 of 4


    California Health & Human Services Agency California Department of Social Services

    INSTRUCTIONS FOR USE OF THE RECIPIENT/EMPLOYER


    RESPONSIBILITY CHECKLIST

    1. This form is used for review with recipients receiving service


    from Individual Providers only.

    2. Counties shall use this form to assure that recipients have


    been advised of and understand their basic responsibilities as
    employers of IHSS providers.

    3. Review each item with the recipient and explain how the
    recipient can comply with each requirement.

    4. Leave a copy of the form with the recipient.

    SOC 332L (1/19) Page 4 of 4

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