New Hire Package - Revised Employee Qualifications, Requirements, And Forms Page 32
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32EMPLOYER CERTIFICATION REGARDING HIGH SCHOOL DIPLOMA,
GED, OR SUBSTITUTE DOCUMENTS
CLASS, DBMD, HCS, MDCP, TxHmL Programs only.
PARTICIPANT NAME (Client): _________________________________________________
APPLICANT NAME (Employee): _________________________________________________
I ________________________________________ certify that I am
The participant
The legally authorized representative
The designated representative.
I certify that I have a copy of the applicant’s (Employee)
High school diploma
GED
The applicant did not have either of these documents.
If the above applicant did not have a copy of his/her high school diploma or GED, I have obtained the
following:
•
documentation of a proficiency evaluation of the employee’s experience and competence to perform
job tasks, including an ability to provide the services needed by the individual, as demonstrated
through a written competency-based assessment; and
•
at least three personal references from people not related by blood that evidence the person’s ability
to provide a safe and healthy environment for the individual.
I understand that I must keep these documents in my employee’s file and produce them at the request of my
case manager/service coordinator, FMSA, and any DADS or HHSC employee, including a utilization review
nurse.
Employer’s Signature:
_____________________________________________
DATE: ___________________________
(fax # 877-726-4919 or email
to New Hire office with application materials.)
Page 32--6/11/15
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