Self Direction Personal Protection Equipment Form

This form is for DSS Program Participants who Self-Direct Supports and Services under
Community First Choice, Acquired Brain Injury, or Homecare Program for Elders


Please complete this form to request immediate and urgent PPE needs to support individuals and protect staff due to COVID19.
*Requests will be fulfilled according to priority and are based on the PPE supplies available to the Department. Individuals requesting PPE must self-direct
their supports. (Please contact your Care Manager if you need assistance submitting this form.)

 
Note: * indicates required fields.


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. Program participant's home address
Note: Supplies can only be mailed to the Program participant's home.
Address1*
Address2
City*
State*
Zip Code*
6.DSS Case Manager's name
First Name
Last Name
7.DSS Case management agency *






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. *

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? *

10. Certain types of equipment require special training and medical evaluations prior to use. One type of special training is called ‘fit testing’. This training ensures that the mask properly fits your PCA. Has your PCA been medically evaluated for wearing certain masks and have they participated in fit testing? *


If yes, please document the manufacturer and model number for the N95 mask that was fit tested.
12. Self Directed staff (PCAs) How many PCAs provide support in your home over the course of a week?
Certification
13. I certify that the PPE supplies requested will be used solely by my PCA staff providing my support while working for me. I understand that proper use of PPE requires that my PCA will leave the PPE in my home at the end of each shift in a paper bag labeled with my PCA’s name so that it can be reused * Note:you must select Yes to have the request considered for fulfillment.

14. I certify that I am the Employer of Record/Sponsoring Person, and currently hire and manage my own staff through my DSS Individualized budget *

15. I certify that I [am a PCA] submitting this form at the request of my Employer who has an individual budget authorized by DSS
Name of PCA

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