{"id":14102,"date":"2026-04-06T13:44:51","date_gmt":"2026-04-06T20:44:51","guid":{"rendered":"https:\/\/ucpofcentralaz.org\/?page_id=14102"},"modified":"2026-04-07T11:31:40","modified_gmt":"2026-04-07T18:31:40","slug":"hcbs-reference-form","status":"publish","type":"page","link":"https:\/\/ucpofcentralaz.org\/es\/hcbs-reference-form\/","title":{"rendered":"HCBS Reference Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_row-fluid qodef-row-over vc_custom_1588660382827 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_inner vc_row-fluid vc_custom_1588785107927 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner vc_custom_1587620256476\"><div class=\"wpb_wrapper\"><div class=\"qodef-shortcode qodef-m  qodef-section-title qodef-alignment--center qodef-title-break--disabled\">\n\t\t\t\t<h2 class=\"qodef-m-title\" >\n\t\t\t\t\tUCP HCBS Reference Form\t\t\t<\/h2>\n\t<\/div>\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<div class=\"wpb_text_column wpb_content_element \">\n<div class=\"wpb_wrapper\">\n<h4 style=\"text-align: center;\">Please complete the questions listed below. Keep in mind that direct care worker services are typically performed unsupervised in the home of a person with physical or developmental disabilities. UCP of Central Arizona will maintain strict confidentiality of your responses in accordance with the law. We appreciate your time and effort.<\/h4>\n<\/div>\n<\/div>\n\n\t\t<\/div>\n\t<\/div>\n<div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">References<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_37'  action='\/es\/wp-json\/wp\/v2\/pages\/14102' data-formid='37' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"246\" \/>\n\t\t\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n\n\t\t\t\t\t<\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_37' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_37_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Applicant:<\/h3><\/div><fieldset id=\"field_37_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_37_1'>*Enter the name of the person who requested this form.<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_37_1'>\n                            \n                            <span id='input_37_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_37_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_37_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_1.4' id='input_37_1_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_37_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_37_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_37_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_37_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Person Completing Form:<\/h3><div class='gsection_description' id='gfield_description_37_24'>Please Note: We cannot accept references completed by family members of the applicant.<\/div><\/div><fieldset id=\"field_37_23\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_37_23'>\n                            \n                            <span id='input_37_23_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_23_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_23.3' id='input_37_23_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_37_23_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_37_23_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_23.4' id='input_37_23_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_37_23_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_37_23_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_23.6' id='input_37_23_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_37_21\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_37_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_37_21_1_container' >\n                                        <label for='input_37_21_1' id='input_37_21_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_21.1' id='input_37_21_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_37_21_2_container' >\n                                        <label for='input_37_21_2' id='input_37_21_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_21.2' id='input_37_21_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_37_21_3_container' >\n                                    <label for='input_37_21_3' id='input_37_21_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_21.3' id='input_37_21_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_37_21_4_container' >\n                                        <label for='input_37_21_4' id='input_37_21_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_21.4' id='input_37_21_4' value=''      aria-required='true'   autocomplete=\"address-level1\" \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_37_21_5_container' >\n                                    <label for='input_37_21_5' id='input_37_21_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_21.5' id='input_37_21_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_37_21_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_37_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_37_2_container'>\n                                <span id='input_37_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_37_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_2' id='input_37_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_37_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_37_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_37_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_37_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_10'>Your Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_37_10' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_37_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Indicate the length of time you have known the applicant: (required\u2014select one):<\/h3><\/div><fieldset id=\"field_37_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Position You&#039;re Applying For<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_3'>\n\t\t\t<div class='gchoice gchoice_37_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Less than 1 year'  id='choice_37_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_0' id='label_37_3_0' class='gform-field-label gform-field-label--type-inline'>Less than 1 year<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 1 year and 3 years'  id='choice_37_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_1' id='label_37_3_1' class='gform-field-label gform-field-label--type-inline'>Between 1 year and 3 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 4 years and 7 years'  id='choice_37_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_2' id='label_37_3_2' class='gform-field-label gform-field-label--type-inline'>Between 4 years and 7 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Between 7 years and 10 years'  id='choice_37_3_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_3' id='label_37_3_3' class='gform-field-label gform-field-label--type-inline'>Between 7 years and 10 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_3_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Over 10 years'  id='choice_37_3_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_3_4' id='label_37_3_4' class='gform-field-label gform-field-label--type-inline'>Over 10 years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_37_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type of relationship (Check all that apply):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_37_27'>Please note that we cannot accept reference completed by family members of the applicant.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_27'>\n\t\t\t<div class='gchoice gchoice_37_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Supervised applicant'  id='choice_37_27_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_37_27\"   \/>\n\t\t\t\t\t<label for='choice_37_27_0' id='label_37_27_0' class='gform-field-label gform-field-label--type-inline'>Supervised applicant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Worked with applicant'  id='choice_37_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_1' id='label_37_27_1' class='gform-field-label gform-field-label--type-inline'>Worked with applicant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Friend'  id='choice_37_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_2' id='label_37_27_2' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Neighbor'  id='choice_37_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_3' id='label_37_27_3' class='gform-field-label gform-field-label--type-inline'>Neighbor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_27_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Other'  id='choice_37_27_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_27_4' id='label_37_27_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_12'>Can you share an example of a time they went above and beyond to help someone in need?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_37_12' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_35'>What were some major accomplishments achieved while working with you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_37_35' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_43'>How would you describe their ability to handle stressful situations?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_37_43' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_44'>What strengths have you observed in their caregiving role?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_37_44' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_37_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If the applicant was a former employee, would you rehire this person?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_37_36'>\n\t\t\t<div class='gchoice gchoice_37_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_37_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_0' id='label_37_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_37_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_1' id='label_37_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_37_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='N\/A'  id='choice_37_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_37_36_2' id='label_37_36_2' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_37_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_37'>Would you recommend this applicant for the Direct Care Worker position? Please share why.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_37_37' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_37_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">By signing and submitting this form, I attest that I am the individual that completed this reference for the applicant listed above. I also agree to be contacted via the phone or email that I listed if further verification or information is needed by the UCP of Central Arizona administrative team<\/h3><\/div><div id=\"field_37_41\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_37_41'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_41' id='input_37_41_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_37_41_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_37_41' width='300' height='180' style='border-style: Dashed; border-width: 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class=\"vc_empty_space_inner\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"UCP HCBS Reference Form Please complete the questions listed below. Keep in mind that direct care worker services are typically performed unsupervised in the home of a person with physical or developmental disabilities. UCP of Central Arizona will maintain strict confidentiality of your responses in accordance with the law. We appreciate your time and effort. 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