Ccl Form 256 - Personnel Records

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PERSONNEL RECORDS
R9-5-402.A., R9-5-403
Employee Name:
1.
:
Date of Birth
:
:
Home Address
Position
:
Telephone #
Alone  Supervised 
2
Start Date:
Hire Date: (if different)
.
3
End Date:
.
4.
Emergency Contact:(name)
Phone #
Mailing address
5.
Immunization Statement: In Compliance with Arizona State Law, the undersigned does hereby testify
that he/she has immunizations against measles, rubella, diphtheria, mumps and pertussis that are
current.
Employee Signature:_______________________________________Date:____________
6-7. Verification of Fingerprint Registration
:
(see A.R.S. § 36-883.02.c, R9-5-203)
Original signed Criminal History Affidavit dated _____________________
Copy of the Applicant Fingerprint Registration Application (application #
)
Copy of the Fingerprint Clearance Card (expiration date
)(#_______
_____)
DPS contacted (date_______________)
Valid
NOT valid
8.
Documents required by R9-5-301(F)
Mantoux TB Test Results (on or w/in 12 months prior to start date) _____________ date of test results
A health care provider’s signed statement that the individual is free from TB, dated w/in 6 months of start date
9
Documents required by R9-5-401
.
saw orig.
(name)
Verified
High School Diploma/GED Certificate
by phone
by:
by letter
Work Experience
(date)
10.
Written Documentation of Training required by R9-5-403
New Staff Training within 10 days of starting date
(date)__________
Eighteen (18) Hours of Annual In-Service Training based on starting date, including at least 6 hours in areas of
child growth & development
YEAR:
(based on start date)
HOURS:
11.
Current License or Certification
AZ Driver’s License
Food Handlers Card
First Aid Certificate
CPR Certificate
(if a van driver)
Expires:_________
Expires:_________
Expires:_________
Expires:__________
12.
Good faith efforts to contact previous employers:
Contact 1
Contact 2
Name:
Date:
Name:
Date:
13.
Central Registry (ADCS) background check
Central Registry (ADCS) Direct Service Position form or Affidavit form
RETAIN ENTIRE FILE 12 MONTHS FROM TERMINATION DATE
G:\Forms\CDC\Personnel records checklist.doc (11/15) CCL form - 256

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