Assistant/substitute Provider Record Form
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1VDSS MODEL FORM - FDH
ASSISTANT/SUBSTITUTE PROVIDER RECORD
FULL NAME OF CAREGIVER: ___________________________________________________________
ASSISTANT
SUBSTITUTE
Street: _____________________________________________________ City: __________________________ State: ______ ZIP: _________
TELEPHONE NUMBER: _________________________________
AGE: _______________________(Attach Verification)
SPOUSE, PARENT, SIBLING OR CHILD OF THE PROVIDER
YES
NO
PERSON TO BE CONTACTED IN CASE OF EMERGENCY:
Name: __________________________________________________
Telephone Number: _____________________
Street: _________________________________ City: __________________________ State: ______ ZIP: _________
EDUCATION (For substitute provider):
(Attach Verification)
PROGRAMMATIC EXPERIENCE (For substitute provider):
(Attach Verification)
DATE OF EMPLOYMENT/VOLUNTEERING: _________________________
TERMINATION DATE: _________________________
ADDITIONAL REQUIREMENTS:
TWO WRITTEN REFERENCES OR NOTATIONS OF VERBAL REFERENCES. (Obtained prior to employment for an assistant or
substitute provider who is not the spouse, parent, sibling or child of the provider)
ORIGINAL BACKGROUND CHECKS (Renewed every three years)
_______________________________
Expiration Date
SWORN DISCLOSURE STATEMENT INDICATING NO BARRIER CRIME (In caregiver record by the first day of employment)
th
CRIMINAL RECORD REPORT INDICATING NO BARRIER CRIME (In the caregiver record by the 30
day of employment)
CHILD PROTECTIVE SERVICES REGISTRY REPORT INDICATING NO FOUNDED COMPLAINT (In the caregiver record by the
th
30
day of employment)
REPORT OF TUBERCULOSIS SCREENING (Obtained every two years)
___________________________________
Expiration Date
DOCUMENTATION OF ORIENTATION TRAINING
DOCUMENTATION OF ANNUAL TRAINING (including annual emergency response training)
Current CPR certification (Renewed every two-three years)
_______________________
Expiration Date
(or documentation of licensure to administer
Current First Aid certification (Renewed every three years) _______________________
prescription medications)
Expiration Date
(or documentation of licensure to administer
Current MAT certification (Renewed every three years)
_______________________
prescription medications)
Expiration Date
FOR SUBSTITUTES, DOCUMENTATION OF TIME OF ARRIVALS AND DEPARTURES
FOR CAREGIVERS PROVIDING TRANSPORTATION, VALID DRIVER’S LICENSE
032-05-0601-00-eng
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