If you would like to become a Direct Care Provider for your loved one, please:

1.) Fill out the linked forms

2.) Give us a call with your questions

3.) When you have completed all the forms, send them our way!

You can upload the completed forms here or

email them to: payroll.otrbg@gmail.com

Please note:  The forms that are fillable can be saved by using the print function.  

Simply choose "Print," "Destination," and "Save as pdf" 

Upload It
Max File Size 15MB

BEFORE WE GET STARTED

To become an Arizona State Licensed Direct Service Provider,

please know that all Arizona State DSP employees are required to use the state-mandated automated clocking in/out system,

AUTO-VISIT, with the use of a cell phone or tablet.  The required app can be obtained on your device's app store.

 

Get started on becoming a Direct Service Provider, by submitting the following documentation:

  • Front & Back of Valid Driver's License

  • Front of your Social Security Card

  • Front & Back of Valid Fingerprint Clearance Card (Must be obtained prior to hiring)

  • Front & Back of Valid CPR/First Aid Card (Must be obtained, prior to hiring - cost covered by OTRBG)

AUTO-VISIT INSTRUCTIONS

STEP 1 ~ GETTING STARTED

Please fill out the application completely and list at least 3 months of relevant care/support experience.

(Must be 18+ old to apply)

Please submit 3 separate references - 2 business & 1 Personal

REFERENCE CHECK  - 3 copies  

(2 Business & 1 Personal)

JOB APPLICATION

AZ DES DIRECT SERVICE

POSITION 

W4

IRS EMPLOYEE

WITHHOLDING FORM

A4

ARIZONA

EMPLOYEE WITHHOLDING

I9

EMPLOYMENT ELIGIBILITY

VERIFICATION

STEP 2 ~ NOTARIZED BACKGROUND CHECKS

OTRBG can notarize these forms for you. 

If you choose this option, you may fill the form out, but please DO NOT sign until we meet in person.

For the Criminal History Self-Disclosure, each box must be checked individually.

ADULT PROTECTIVE SERVICES (APS) AFFIDAVIT

CRIMINAL HISTORY SELF DISCLOSURE AFFIDAVIT

STEP 3 ~ AGREEMENTS, AUTHORIZATIONS, AND PERMISSIONS... OH MY!

Please fill out the employee agreement of standards and permission forms.

Please fill out and sign the Direct Deposit form to obtain your paycheck.

For your protection, it is highly recommended that care providers obtain the Hepatitis B immunization.  

This is optional and OTRBG offers this vaccine free of charge. 

If you decline to receive this vaccine, please fill out the Hepatitis B Declination form.

If you change your mind, you can receive this vaccination at any time during your employment by letting your supervisor know.

AGREEMENT OF STANDARDS

PREVENTION OF 

STATE DUPLICATE BILLING

AHCCCS & DDREPORTS

PERMISSIONS

DIRECT DEPOSIT

AUTHORIZATION

HEPATITIS B

DECLINATION

NEARLY DONE! - DRIVER?

IF you plan on providing transportation for your loved one, for medical or recreational purposes while working, 

please fill out the driver form, permission to obtain DMV record, and please submit the following:

  • Copy of current vehicle insurance

  • Copy of current vehicle registration

DRIVER/MVD PERMISSION

FORM

** Please Note**

Per insurance requirements,

OTRBG is required to do a vehicle inspection on any vehicle being used to transport clients while working. 

Please review the Supervisor Inspection Form used when conducting an inspection

and make any necessary repairs to your vehicle prior to inspection.

Thank you!

NON-DRIVER?

IF you DO NOT plan on providing transportation for your loved one, for medical or recreational purposes while working, 

please fill out the NON-DRIVER DECLINATION FORM below:

***IF AT ANY TIME, YOU CHANGE YOUR MIND ABOUT BECOMING A DRIVER OR DISCONTINUING DRIVING, YOU ARE REQUIRED TO FILL OUT NEW DOCUMENTATION INDICATING SUCH.

NON-DRIVER DECLINATION FORM

Supervisor Inspection

Form

LAST STEP - RESPONSIBLE PARTY?

If you are responsible for your loved one please fill out the following forms:

SIGNATURE VERIFICATION

GUARDIAN UNDERSTANDING OF AUTO-VISIT SIGNATURE

CERTIFICATIONS

After being hired, you will be trained by OTRBG in the following certifications:

  • Article 9 (Prior to providing care)

  • Arizona Direct Care Worker (DCW) Fundamentals & Developmental Disabilities Training (Within 90 days of hire date) 

IF YOU HAVE TAKEN THESE COURSES WITH ANOTHER AGENCY, BUT DO NOT HAVE DOCUMENTATION OF CERTIFICATES OF COMPLETION

Please fill out the following form:

CERTIFICATION ACKNOWLEDGMENT FORM

HIRING HANDOUTS

Please take a moment to read the following:

UNDERSTANDING STATE BILLED HOURS

PAYROLL & PAY PERIOD

DUE DATES

ON-CALL NOTIFICATION

SHELTER-IN-PLACE

HEALTH INSURANCE

MARKET PLACE COVERAGE

Call Us: 1-928-606-1697   /   overtherainbowbutterflygarden@gmail.com   /  2722 N. West St. Flagstaff, AZ. 86004

  • Facebook

Copyright 2018 | Over the Rainbow Butterfly Garden, Inc. | All Rights Reserved