Personnel Information Form - Washburn Center For Children

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Personnel Information Form
dhs-5422-eng
4-08
(was ms-2076)
Please keep a copy of this form in the staff file.
You are asked to supply the data on this form so that the Minnesota Department of Human Services may evaluate your agency’s
request for licensure.
This form must be submitted to DHS for each employee at the time of initial licensing or relicensing. Attach any supporting
documentation of qualifications such as copies of transcripts.
Identifying information:
Program licensing No. __________________
804542
name of emPloyee
date of birth
name of Program
address of Program
Family Focused
2430 Nicollet Ave. S., Mpls.
date of emPloyment
job title
Volunteer
Alternatives for staff qualification:
Refer to Minnesota Rules, parts 9503.0031 - 0034 to determine which alternative is appropriate for the position you hold.
Teacher
1
2
3
4
5
6
7
8
9
Assistant Teacher
1
2
3
4
5
6
7
8
9
l
Aide:
l
l
Volunteer:
Other:
x
l
Director:
Licensor's Initials __________ Date: _________________
All staff must meet applicable employment conditions, staff qualifications and training as required in MN Rules, parts 9503.0005
(refer to the back of this form for an explanation of qualification requirements.
through 9503.0170.
)
1.
Circle the appropriate number representing how a teacher or assistant teacher qualifies for the position.
2.
Place in the personnel file on site legible copies of documents from post secondary training institutions: transcripts,
diplomas, grade cards, certificates, etc.
Child care experience to date: (most recent first)
1.
experience means paid or unpaid employment as a teacher, assistant teacher, aide, or student intern in a public or nonpublic school
serving children 12 years and under, in a licensed child care center or hours worked as the holder of a mn license as a family day
care provider.
Name & address of employer
Job title
Dates of employment
Total hours
worked
from:
to:
from:
to:
from:
to:
total hours worked to date:
signature of emPloyee
date
signature of suPervisor reviewing this form
date
Orientation documentation:
I received an orientation required under MN Statutes, Section 245A.40, subd. 1, before starting work with children. The
orientation included: A. the center’s philosophy, child care program, and procedures for maintaining health and safety, and
handling emergencies and accidents; B. specific job responsibilities; C. the behavior guidance standards specified in part
9503.0055; and D. the reporting responsibilities specified in MN Statutes, sections 626.556 (Reporting Maltreatment of Minors),
245A.66, and MN Rules, part 9503.0130, subpart 1.
I received training in the program’s Drug and Alcohol Policy.
emPloyee's signature
date

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