The Collaborative NJ Interactive Map: Self-Directed Employee Form

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This form is for Self-Directed Employees that wish to post or update their availability on The Interactive Map.

FAQs: https://docs.google.com/document/d/1mN_-vxQTxG1ahzziztXtsb5k0Ok-dVMoFO8EA3htY5Y/edit?usp=sharing

Email *

Select one of the following *

This is my first time filling out this form/I would like to be listed on the map

I have previously filled out this form, but I would like to update my listing

What is your name? *

How many years of experience do you have as a Direct Support Professional or Self-Directed Employee? *

Your Phone Number *

Your Days/ Hours of Availability to work: *

Your Location (City, ST): *

Your Zip code/County: *

List the towns you are interested in working. *

The fiscal intermediaries you currently enrolled with: *

Public Partnerships Group (PPL)

Easterseals

Both PPL and Easterseals

None

Your gender: *

Female

Male

Other:

Do you have any of the following certifications? *

CPR

AED

First Aid

Other

Required

Have you passed the NJ state requirements for SDEs within the last 6 months? *

Fingerprinting

Drug testing

CARI check

Other

Are you able to drive the person you would support using your own vehicle? *

Yes

How did you learn about The Interactive Map?

Additional notes

A copy of your responses will be emailed to the address you provided.

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