Please answer all questions to the best of your ability.
0. Who is filling out the form?
Please select...
Caregiver
Consumer
LA PASC / CCA IHSS Caregiver EDR & ADRD Training
1. Today's Date
2. IHSS ID Number
3. First Name
4. Middle Name
5. Last Name
6. DOB
7. Email
8. Phone Format: 1234567890
8.5. Mailing Address line 1
8.5. Mailing City
9. Mailing State/Province
10. Mailing Zip/Postal Code
11. County
14. How do you describe yourself?
Please select...
Female
Male
Transgender
Gender nonconforming / genderqueer
A different identity
Prefer not to answer or do not know
15. What is your race? (check all that apply)
American Indian/Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Not listed here
Prefer not to answer or do not know
16. How did you find out about us? Check all that apply
Employer/Consumer
Provider
SEIU ULTCW / Local 2015
Phone Call
Health Plan/Insurance
House Visit
Community Presentation
Media
Letter
Friend/Another Consumer
Other
Friend/Another IHSS Caregiver
Flyer
Community
Presentation
17. Which device do you use to go online? Check all that apply
Smartphone
Computer
Tablet
Laptop
18. Other classes you're interested in:
Autism
Diabetes Care
CNA
Other
19. Is your Recipient/Caregiver a family member?
Yes
No
20. What language you can speak?
Armenian
Cantonese
English
Korean
Mandarin
Spanish
Other
IHSS Form Program
