O
L
FFICE OF
ICENSING
D
B
H
D
S
EPARTMENT OF
EHAVIORAL
EALTH AND
EVELOPMENTAL
ERVICES
STAFF INFORMATION SHEET
NAME OF SERVICE:_____________________________________
DATE: ____________________________
_____________________________________
LOCATION:
Position
Staff Member
Service
SCHEDULED HOURS
(use * to denote
Education Level
Assigned
Name
position vacancy)
and Credentials
MON
TUES
WED
THURS
FRI
SAT
SUN
Use @ to indicate staff having current certification in First Aid. Use # to indicate staff who have received a certificate in
Cardiopulmonary Resuscitation (CPR).