Self Direction Personal Protection Equipment Form, DSS

1. Program Participant Supported by DSS

First Name

Last Name*

DOB

(MM/DD/YYYY)

2. Employer of Record (EOR) (EOR is the Program Participant or someone the Program Participant asks to act on their behalf to hire staff and sign timesheets.

First Name

Last Name*

3. EOR Contact email address*

4. EOR Contact 24-hour phone number*

5.Address of person receiving supports where supplies will be used by staff

Address1*

Address2

City*

State*

Zip Code*

6.DSS Case Manager's name (if known)

First Name

Last Name

7.DSS Case management agency *

Eastern region – Connecticut Community Care Access Agency

North Central region – Connecticut Community Care Access Agency

Northwest region – Connecticut Community Care Access Agency

City of Waterbury – Western Connecticut Area Agency on Aging

South Central – Agency on Aging of South Central Connecticut

Southwest – Southwestern CT Agency on Aging

I don't know my DSS Region

8. If you receive medical procedures that make tiny drops of saliva, like open suction, nebulizer, BIPAP or CPAP treatments and your employees help you with this, they may need a different type of PPE. These treatments can put coronavirus in the air, putting your PCA at more risk of getting coronavirus from you if you have it. Please indicate if you are receiving any of the aerosol treatments described above that will require your PCA to use an N95 respirator mask or appropriate substitute. *

Yes

If yes, please indicate who helps you with this medical procedure. For example, if you do it yourself, answer ‘self’. If an unpaid family member helps you, answer ‘family’. If you pay someone to help you, answer by providing the name of the employee, even if the employee is a family member.

9. Is there a person diagnosed as COVID-19 + or under investigation for COVID-19+ in the home? *

Yes

10. Please select the preferred glove size in the drop down below.* Note: If the preferred glove size is not available, requests will be filled with the closest possible alternative size.

11. Self Directed staff (PCAs) How many PCAs provide support in your home over the course of a week?

Certification

PLEASE remind your staff to wash their hands regularly, keep their hands away from their face, and wear a mask when they are working in your home. Review guidelines for reusing PPE. All PPE is assigned for use and reuse to a single PCA. PPE is NEVER shared. Masks: It is each employee’s responsibility to maintain and care for their mask each week. Medical grade masks may be reused by the PCA more than once as long it isn’t damaged in some way. Masks should be stored in a paper bag with the PCA’s name on it in between uses. If medical grade masks are not available, cloth masks, bandanas, or scarves may be used. Gloves, Gowns, Eye Protection: IF you have tested positive for COVID-19 or are symptomatic and being tested for COVID-19 or if your PCA helps you with procedures that make tiny drops of saliva, like open suction, nebulizer, BIPAP or CPAP treatments, your PCA  should use gloves, gowns, and eye protection in addition to the appropriate mask, if available. Exposure Protocol: If your PCA works in close proximity (6 feet or less) and for a prolonged period of time (more than 15 minutes) and you are diagnosed with COVID-19, your PCA can continue to work as long as your PCA is asymptomatic. Employees should contact their healthcare provider and continue to wear a mask when working.  PCAs should not work for you if they have tested positive for COVID 19 or have signs or symptoms of COVID.

12. I certify that the PPE supplies requested will be used solely by the PCA staff providing the support. * Note:you must select Yes to have the request considered for fulfillment.

Yes

13. I certify that I am the Employer of Record/Sponsoring Person, and currently hire and manage my own staff through my DSS Individualized budget or their designee who has been given permission to fill out this form on their behalf. *

Yes

Input the text showing in the image *