If you are searching a housekeeping service and finding a good households keeper, the following interactive document on housekeeping sevices agreement must provides you the standard information to create a valid housekeeping service agreement.
CONTENT
Living room/Dining room, Floor, Dust (e.g., tables, furniture), Other (Specify)
Miscellaneous Duties, Take out garbage (Curb side only), Wash laundry Hand Machine, Dry laundry Hand Machine, Fold laundry, Shopping for food and household, Other (Specify)
COMMENTS/SPECIALIZED INSTRUCTIONS (e.g., list cleaning methods - vacuum, sweep, mop, scour with cleanser, disinfect, wipe down with cleaner, etc.)
AGREEMENT
THIS IS A MUTUAL AGREEMENT BETWEEN THE RESPONSIBLE PERSON OF
(Print name of responsible person)
(Print name of individual with developmental disabilities)
AND THE HCBS SERVICE PROVIDER
(Print name of HCBS Service Provider)
SIGNATURE OF RESPONSIBLE PERSON DATE
SIGNATURE OF HCBS SERVICE PROVIDER DATE
SIGNATURE OF SUPPORT COORDINATOR DATE
REQUIREMENTS/LIMITATIONS
The individual/family is responsible for providing all cleaning supplies.
The service is to be performed only for the individual’s personal area(s) (e.g., bedroom, bathroom) and/or common areas of the home used by the individual.
The service is not authorized to include cleaning after parties, preparing meals for the whole family, major carpet cleaning (i.e., shampooing), routine lawn and yard care, or pet care and cleaning pet accidents.
Cleaning of dishes is limited to two meals worth of dishes.
Prior Support Coordinator approval is necessary for heavy cleaning, such as cleaning ceilings, moving heavy furniture and/or appliances, washing walls, etc.
Prior Support Coordinator approval is necessary for yard work: hauling debris; hauling water; gathering, hauling, sawing and chopping wood; caring for livestock used for consumption.
The individual/family is responsible to provide the money for supplies and food in advance of the purchase if the provider is expected to shop for food and household supplies.
If shopping is an expected part of the service, the shopping is done within the time allocated for the service.
Laundry is limited to the individual’s clothing, bed and bath linens.
EQUAL OPPORTUNITY EMPLOYER/PROGRAME
Under the Americans with Disabilities Act (ADA), the Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service, or activity.
For example, this means that if necessary, the department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity.
If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible.
This document is available in alternative formats by contacting ________.
