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Form Dhcs 5050 - California A-5 Facility Staffing Data - Health And Human Services Agency

STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

A-5 – FACILITY STAFFING DATA - Page 1

INSTRUCTIONS: Use this double sided form to identify all staff of the facility. Designate volunteers by placing a “V” after their names. Use additional sheets as needed.

Counselor Information

(A minimum of 30% of all staff who provide counseling services shall be

Facility Name:

Provider #:

licensed or certified.)

* Certified/Registered

First Aid and CPR required for

licensed facilities only.

(Provide certification/registration

Effective and

# and organization (list below)

expiration dates of:

Last TB

** Licensed As:

First Aid:

CPR:

Licensure, Certification,

Employee Information:

Date Hired

Test Date

A. Psychologist

D. LCSW

or Registration

Date of last

B. MFT

E. Registered

Training

C. Physician

Intern

Yes

Certification/registration #

Effective date

Title:

Scheduled hours per week:

N/A

Lic/Cert/Reg organization

Expiration date

Yes

Certification/registration #

Effective date

Title:

Scheduled hours per week:

N/A

Lic/Cert/Reg organization

Expiration date

Yes

Certification/registration #

Effective date

Title:

Scheduled hours per week:

N/A

Lic/Cert/Reg organization

Expiration date

Yes

Certification/registration #

Effective date

Title:

Scheduled hours per week:

N/A

Lic/Cert/Reg organization

Expiration date

Yes

Certification/registration #

Effective date

Title:

Scheduled hours per week:

N/A

Lic/Cert/Reg organization

Expiration date

DHCS 5050 (7/13)

* APPROVED CERTIFYING ORGANIZATIONS

1. Board for Certification of Addiction Specialists (CAARR)

4. Breining Institute

2. California Certification Board of Alcohol and Drug Counselors (CAADAC)

5. California Association of Drinking Driver Treatment Programs (CADDTP)

6. American Academy of Health Care Providers in the Addictive Disorder (AAHCPAD)

3. California Association of Alcohol/Drug Educators (CAADE)

** LICENSED PROFESSIONALS AND INTERN QUALIFICATION REQUIREMENTS

Licensed professional means a physician licensed by the Medical Board of California; a psychologist licensed by the Board of Psychology; or a clinical social worker or MFT licensed by the California

Board of Behavioral Sciences, or an intern registered with the California Board of Behavioral Sciences or with the Board of Psychology.