CCL-205 Staff Non Staff Record Summary Excel Oct 2018
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CCL-205
Staff/Non-Staff Record Summary
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Director Name:
Facility Name: Certificate Number:
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Insturctions:
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* List all individuals working at the facility including: staff, substitutes, volunteers, janitors, cooks, bus drivers, secretaries, speech therapist, occupational therapist, social/family aides, etc. (Section 1 and Section 2)
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* For FCCHs and FCCCs that are in a residence, all household members example Spouse, Adult Child, Relative, Friend, etc. age 18 years and older must also be listed, even if not present when children are in care (Section 1)
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Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
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1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with infants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
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2.

3.
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2.

3.
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2.

3.
1.

2.

3.
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2.

3.
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2.

3.
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2.

3.
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2.

3.
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Page2
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Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
15
1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with i nfants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
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1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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2.

3.
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2.

3.
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2.

3.
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2.

3.
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2.

3.
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2.

3.
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Page3
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Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
25
1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with infants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
26
1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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Page4
34
Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
35
1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with infants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
36
1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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Page5
44
Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
45
1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with infants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
46
1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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Page6
54
Section 1:
Required for all
Section 2
Required for individuals providng direct care to children
55
1. Name

2. Date of Birth

3. Position or Job
Title: example Assistant
Director, Infant Director
Start Date
or
Date Moved
into the Home
Central
Registry
Check


Date and
Results
Passed
yes or no
Out-of- State
Abuse
Neglect
Check

Date and
Results
Passed
yes or no
Sex Offender Check



Date and
Results
Passed
yes or no
DCI/FBI Fingerprint Check


Date and
Results
Passed
yes or no
Risk
Assessment
yes or no
OR
TB Test
Date and
Results
Positive or
Negative
Used to
meet
Saff:Child
ratios or
direct
care of
children
yes or no
Used 24
Hours or
More per
month in
direct
care of
children
yes or no
1. Facility Staff
Orientation Date

2. Pre-Service
Date

3.ELG and
ELF Date
Infant/CPR
Expires
Date


First Aid
Expires
Date
Works
with infants
yes or no

Transports
Children
yes or no


Driver's
License
expiration
date
56
1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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2.

3.
1.

2.

3.
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1.

2.

3.
1.

2.

3.
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