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The Collaborative NJ Interactive Map: Self-Directed Employee Form
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
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* Indicates required question
Email
*
Your 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?
*
Your answer
How many years of experience do you have as a Direct Support Professional or Self-Directed Employee?
*
Your answer
Your Phone Number
*
Your answer
Your Days/ Hours of Availability to work:
*
Your answer
Your Location (City, ST):
*
Your answer
Your Zip code/County:
*
Your answer
List the towns you are interested in working.
*
Your answer
The fiscal intermediaries you currently enrolled with:
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Public Partnerships Group (PPL)
Easterseals
Both PPL and Easterseals
None
Your gender:
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Female
Male
Other:
Do you have any of the following certifications?
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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
No
How did you learn about The Interactive Map?
Your answer
Additional notes
Your answer
A copy of your responses will be emailed to the address you provided.
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