Support Service Worker (SSW) Biennial Qualification Form
Participant, Common Law Employer, and SSW Information:
Name of Participant: ___________________________________________________PPL ID#: _________
Name of Common Law Employer: _________________________________________________________
Name of SSW being qualified: ____________________________________________PPL ID#: _________
SSW Termination If the SSW no longer works for you, please complete the termination information below and return this page to PPL. You do not have to complete the remaining sections of the form.
Last Date of Employment:
Reason for Termination: Failed to report to work for ____ days Quit with verbal notice Quit with written notice No longer had work available for the SSW at time of separation (lay‐off) Dismissed (fired) for the following reasons: ____________________________________
Signature of CLE: _____________________________________Date: ___________
Purpose of the Qualification Process: The biennial qualification requirement is specified in ODP’s approved Consolidated and Person/Family Directed Support Waivers. All SSWs are required to be qualified every two years regardless of how long they have been hired and providing services to a waiver participant through the Vendor Fiscal/Employer Agent (VF/EA) Financial Management Services Model. Qualification Verification: By placing your initials for the following statements, you are confirming that the Support Service Worker will continue to meet the following waiver standards and ODP qualification requirements. 1. The SSW will comply with Department standards related to provider qualifications. SSW’s Initials: _______ CLE’s Initials: _______ 2. The SSW is trained to meet the needs of the Participant; which includes, but is not limited to: communication, mobility, and behavioral needs. SSW’s Initials: _______ CLE’s Initials: _______
3. The SSW has been trained on the ISP and agrees to carry out ISP responsibilities. SSW’s Initials: _______ CLE’s Initials: _______
SSW Biennial Qualification Form v2.0
Participant PPL ID#_________ SSW PPL ID#_________
Page 1 of 5 Please fax form to 1‐855‐405‐7037
Support Service Worker (SSW) Biennial Qualification Form
Qualification Verification (continued): The following TWO questions MUST be answered by checking the appropriate box.
1. Is the SSW a Relative of the Participant?
YES, the SSW is a relative of the participant. What is the relationship of the SSW to the participant? Spouse Parent of an adult child Stepparent of an adult child Grandparent Brother Sister Half‐Brother Half‐Sister Aunt Uncle Niece Nephew Adult child or stepchild of a Adult grandchild of a parent with an intellectual grandparent with an disability intellectual disability 2. Is the SSW a Court‐appointed Legal Guardian of the Participant?
NO, the SSW is not a relative of the participant (for example, friend, neighbor, hired SSW)
YES, the SSW is a Court‐appointed Legal Guardian.
NO, the SSW is not a Court‐
appointed Legal Guardian.
Transportation: Will the Support Service Worker provide Transportation to the participant?
YES NO
If YES, the following must be submitted to Public Partnerships, LLC with this form: 1. A copy of valid Driver’s License showing state licensed under, license number, and expiration date. 2. A copy of the current state Motor Vehicle Registration. 3. A copy of Automobile insurance certificates for all automobiles owned, leased, and/or hired with policy numbers and expiration dates. 4. Date of last vehicle inspection: ________________
SSW Biennial Qualification Form v2.0
Participant PPL ID#_________ SSW PPL ID#_________
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Support Service Worker (SSW) Biennial Qualification Form
Support Broker Services (W7096) If your SSW is being hired to provide support broker services:
You must submit documentation of training in principles of self‐determination, participant directed services and person centered thinking (if assisting in planning meetings), training in basic employment law, one year of experience in a management position with human resource responsibilities, or have a degree in human resources. Will the Support Service Worker provide Support Brokerage Services?
YES NO
If YES, the following section must be completed and documentation provided:
Documentation for the following must be submitted to Public Partnerships, LLC with this form. Check the box to indicate documentation received, reviewed and attached.
Training in:
The principles of self‐determination, Participant directed services, and Person centered thinking (if assisting in planning meeting).
Documentation for one or more of the following must be submitted to Public Partnerships, LLC with this form. Check the appropriate box to indicate documentation, received, reviewed and attached.
Training in basic employment law (this
One year of experience working in human
training should include the following topical areas: discrimination law, wage and hour law, confidentiality and workplace safety).
resources (this should include experience recruiting, screening, interviewing and managing employees).
One year of experience in a management
Certificate or degree in human resources
position with human resource responsibilities.
from an accredited post‐secondary academic institution.
SSW Biennial Qualification Form v2.0
Participant PPL ID#_________ SSW PPL ID#_________
Page 3 of 5 Please fax form to 1‐855‐405‐7037
Support Service Worker (SSW) Biennial Qualification Form
Enhanced 1:1 Home and Community Habilitation or Enhanced 1:1 Respite: If your SSW is being qualified to provide Enhanced 1:1 services under Home and Community Habilitation or Respite, as authorized on the ISP: You must submit a copy of the SSWs Nursing License and/or four year degree.
Enhanced 1:1 Home & Community Habilitation Procedure Codes ‐ W7061 Enhanced 1:1 Respite Procedure Codes ‐ W7251, W7264, W8003, W8013
Will the Support Service Worker provide Enhanced 1:1 Home & Community Habilitation or Enhanced 1:1 Respite?
YES NO If YES, the following section must be completed and documentation provided: By placing your initials below, you are confirming that the CLE has received, reviewed and attached a copy of current Nursing License/degree documentation. SSW’s Initials: _______ CLE’s Initials: _______
What type documentation has been received, reviewed and attached?
Current Nursing License
Four year degree (copy of diploma)
Enhanced 2:1 Home and Community Habilitation or Enhanced 2:1 Respite: “The provision of the service at a staff‐to‐individual ratio of 2:1 with at least one staff member who has at a minimum a 4 year degree or who is a licensed nurse. The second staff member must have at least a high school diploma.” If your SSW is being qualified to provide Enhanced 2:1 services under Home and Community Habilitation or Respite, as authorized on the ISP: You must submit a copy of the SSWs Nursing License and/or four year degree or high school diploma. Enhanced 2:1 Home & Community Habilitation Procedure Codes ‐ W7069 Enhanced 2:1 Respite Procedure Codes ‐ W7253, W7266, W8005, W8015
Will the Support Service Worker provide Enhanced 2:1 Home & Community Habilitation or Enhanced 2:1 Respite?
YES NO SSW Biennial Qualification Form v2.0
Participant PPL ID#_________ SSW PPL ID#_________
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Support Service Worker (SSW) Biennial Qualification Form
Enhanced 2:1 Home and Community Habilitation or Enhanced 2:1 Respite: (continued) If YES, the following section must be completed and documentation provided:
By placing your initials below, you are confirming that the CLE has received, reviewed and attached a copy of current Nursing License/degree documentation or High School Diploma. SSW’s Initials: _______ CLE’s Initials: _______
What type documentation has been received, reviewed and attached?
High school diploma
Current Nursing License Four year degree (copy of diploma)
Criminal Background Checks: In accordance with the currently approved waivers, SSWs must: Have criminal clearances as per 35 P.S. §10225.101 et seq. and 6 Pa. Code Chapter 15. Have child abuse clearances (when the Waiver participant is under age 18) as per 23 Pa. C.S. Chapter 63. PPL is able to provide copies of criminal background checks to Common Law Employers upon request. SSW Attestation: By signing this form, I do verify, that I have read and/or have had the Individual Support Plan read to me, and I understand the requirements. I attest that I shall report any change that may affect my qualification status listed above or in the approved Waivers to my Common Law Employer within 5 business days of the change occurring. Signature of the SSW or back‐up SSW: ___ Date: Common Law Employer Attestation: By signing this form, I do verify, that I have read and/or have had the requirements of the approved waiver read to me, and I understand these requirements. I verify that I will submit all required SSW qualification documentation to the VF/EA. I also verify that I am in compliance with the waiver requirements. I attest that I shall report a change in my SSW’s qualifications status, by submitting a new Support Service Worker (SSW) Qualification Form to Public Partnerships, LLC within 5 business days of being notified of the change. Signature of Common Law Employer: ___ Date: SSW Biennial Qualification Form v2.0
Participant PPL ID#_________ SSW PPL ID#_________
Page 5 of 5 Please fax form to 1‐855‐405‐7037