Shared Living Provider Questionnaire

Maine Department of Health and Human Services
Aging and Disability Services
11 State House Station
41 Anthony Avenue
Augusta, Maine 04333-0011
Tel; (207) 287-9200; Toll Free: (800) 262-2232
Fax (Disability) (207) 287-9915; Fax (Aging) (207)287-9229
TTY: Dial 711 (Maine Relay

Janet T. Mills
Governor

Jeanne M. Lambrew, Ph.D.
Acting Commissioner

Business name (may be your personal name):
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Years at current address:
Years at prior address:
Phone # - ### - ### ####
Cell phone# - ### - ### ####
Email Address:
Names of other adults (over 18) living in the home:
How did you learn about being a Home Provider or Respite Provider?
Newspaper/Advertisement Agency contact Word of Mouth/Relative or Neighbor Other Source (please specify): Other Source (please specify):
Contractor Information and Qualification Questions:
1. Do you understand that you and the other adults living in your home will be subject to multiple types of background checks before completing this process?

1. Do you understand that you and the other adults living in your home will be subject to multiple types of background checks before completing this process? Yes No
2. Are you a legal resident of Maine or the United States?

2. Are you a legal resident of Maine or the United States? Yes No
3. Do you have a valid Maine Driver's License?

3. Do you have a valid Maine Driver's License? Yes No
4. Do you have an automobile and insurance for the automobile?

4. Do you have an automobile and insurance for the automobile? Yes No
5. Have you ever been investigated for abuse/neglect to children or other individuals?

5. Have you ever been investigated for abuse/neglect to children or other individuals? No Yes (If yes, explain below) Yes (If yes, explain below)
6. Have you ever had a license or certification, to operate a residential care facility denied or place on conditional status?

6. Have you ever had a license or certification, to operate a residential care facility denied or place on conditional status? No Yes (If yes, explain below.) Yes (If yes, explain below.)
7. Are you currently a home provider or has your home ever been certified?

7. Are you currently a home provider or has your home ever been certified? No Yes (If so what agency certified your home?)
8. Have you, or anyone in the household, been convicted of any crime?

8. Have you, or anyone in the household, been convicted of any crime? No Yes (If yes, explain below.) Yes (If yes, explain below.)
9. Has anyone in the household ever been the subject of an investigation by a State agency involving the rights, abuse or exploitation of someone in their care/custody?

9. Has anyone in the household ever been the subject of an investigation by a State agency involving the rights, abuse or exploitation of someone in their care/custody? No Yes (If yes, explain below) Yes (If yes, explain below)
10. Are you on the Medicare Exclusion list with the Office of the Inspector General?

10. Are you on the Medicare Exclusion list with the Office of the Inspector General? No Yes (If yes, explain below.) Yes (If yes, explain below.)
Personal References:

(Other than family members. Do not include work relationships)
1) Name First Last
Phone - ### - ### ####
Relationship
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
2) Name First Last
Phone - ### - ### ####
Text
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3) Name First Last
Phone - ### - ### ####
Text
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
May OACPDS or a contracting agency contact the above references?

May OACPDS or a contracting agency contact the above references? Yes No
Contractor Living Situation, Home Environment and Physical Plant
Do you own your home (__) or rent (__)? (check one)
Home Rent
Do you have Home Owners / Renters Insurance?

Do you have Home Owners / Renters Insurance? Yes No
Do you see any changes in your current living situation in the next year?

Do you see any changes in your current living situation in the next year? Yes No
Do you understand that you may be required to update your home to meet certification standards in order to be eligible for this program?

Do you understand that you may be required to update your home to meet certification standards in order to be eligible for this program? Yes No
Experience, Educational and Training History
Do you have a High School Diploma or a GED?

Do you have a High School Diploma or a GED? No Yes, from where? Yes, from where?
Are you certified as a CRMA / DSP/ BHP / CNA / PSS / First Aid / CPR (check all that apply)
CRMA DSP BHP CNA PSS First Aid CPR
Please list other educational experiences, trainings and certifications:
What prompted you to pursue becoming a residential provider for a person with disabilities?
Professional History

Most Recent Work: (please list at least 3, Homemaker is acceptable to list)
a) Business/Company Name:
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Supervisor:
Dates of service:
Start Date: / MM / DD YYYY
End Date / MM / DD YYYY
Position:
Reason for leaving:
b) Business/Company Name:
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Supervisor:
Dates of service:
Start Date: / MM / DD YYYY
End Date: / MM / DD YYYY
Position:
Reason for leaving:
c) Business/Company Name:
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - ### - ### ####
Supervisor:
Dates of service:
Start Date: / MM / DD YYYY
End Date: / MM / DD YYYY
Position:
Reason for leaving:
May DHHS-OADS or a contracting agency contact the above individuals or entities for references regarding your ability to care for people?

May DHHS-OADS or a contracting agency contact the above individuals or entities for references regarding your ability to care for people? Yes No
Have you received a copy of the Shared Living Handbook?

Have you received a copy of the Shared Living Handbook? Yes No
Please describe your experience with people with disabilities or other human services below:
PLEASE NOTE! In order to be considered as an independent contractor to provide MaineCare services, it will be necessary to answer some very personal questions regarding yourself and members of your household.

The process for engaging as a Shared Living Home Provider consists of, at a minimum, the following steps:
• Obtain and review the Shared Living Option Handbook issued by the State.
• Complete the Shared Living Questionnaire.
• Submit this questionnaire to any (and every) Administering Agency that provides oversight to Shared Living Option services. A list can be found on the DHHS-OADS website, providers are listed by counties. http://www.maine.gov/dhhs/OACPDS/DS/resource_directory/index.shtml
• As a Shared Living Home Provider you must meet the following basic requirements of MaineCare, the Shared Living program and the Section 21 Waiver program:
o Background checks for you and those that live with you over the age of 17.
o Meet with each agency you may hope to contract with.
o Have a home inspection performed by each agency.
o Training requirements must meet State requirements and be within certain time frames depending on the training, which are:
- Shared Living Option Medication course or CRMA
- Direct Support Professional (DSP)
- Other trainings as required by the individual’s team.

If you are certified as a Shared Living Home Provider, additional questions will be asked of you to assist the individual, their family, their team members, case worker and the Administering Agency in making the best possible decision/match in order to provide quality supports for each individual. When a match is made, the Administering Agency and you will enter into a formal contract for you to provide Shared Living services as an independent contractor.

Thank you for your honest and candid responses.
Draw your signature into the box below. *

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Date * / MM / DD YYYY
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Shared Living Provider Questionnaire

Shared Living Provider Questionnaire

Contractor Information and Qualification Questions:

Personal References:

Contractor Living Situation, Home Environment and Physical Plant

Experience, Educational and Training History

Professional History