Admin CDSS LIC 311C - Personnel Records CDSS On-line Forms and Publications
Download Camellia # LIC 501, LIC 503 LIC 508 LIC 9163 & SOC 341A, Click here - LIC 311C Personnel Record needed for New Employee
A. LIC 503 Health Screening Report - Facility Personnel [with Tuberculosis (TB) clearance]
B. TB clearance and "good health" statement from volunteer(s).
C. LIC 501 Personnell Record-employment application form completed by each staff member.
D. LIC 500 Personnel Report-showing current roster .
E, Criminal Record Statement for persons subject to fingerprint requirements (LIC 508) and Department of Justice Clearance Letter ‘No Criminal Record’ for each staff or adult residing in the facility, exemption approval,
or Criminal Record Exemption Transfer Request (LIC 9188)
F. Licensee's affidavit on persons exempt from fingerprint requirements [if not on LIC 500 (see section D)].
G. Verification of education, experience, training and/or license/certificate for the administrator, staff and consultants.
H. Verification of training in first aid for persons responsible for providing direct care andsupervision.
I. Valid water safety certificate for any adult giving water activity staffing responsibility.
J. Documentation of employee training for each staff, including DOJ Abuse Reporting Training.
K. Statement Acknowledging Requirement To Report Suspected Abuse Of a Dependent Adult or Elder (SOC 341A)
1. LIC 9163 Live Scan Application. LIC 9194 Live Scan Instructions (For State Licensed Facilities)