FACILITY: NAME: NAME: NAME:
PCID: (CHECK ONE)
Director GS
AGS AIDE
Primary Secondary
(CHECK ONE)
Director GS
AGS AIDE
Primary Secondary
CHECK ONE:
CCC GCCH FCCH
INSPECTION DATE: WORK HOURS: WORK HOURS: WORK HOURS:
CERT REP: ASSIGNED ROOM/LOCATION: ASSIGNED ROOM/LOCATION: ASSIGNED ROOM: LOCATION
CHILD CARE STAFF DATA
The following information must be maintained in the staff record:
First day working in child care
Employee address in record
Yes No Yes No Yes No
Date of birth
Date of disclosure statement
Request date – State Police Clearance
Request date – Child Abuse Clearance
Date employee fingerprinted
90-day provisional hire end date
Suspended date | Return date
Date of FBI clearance
Date of NSOR verification certificate
PREVIOUS MOST RECENT PREVIOUS MOST RECENT PREVIOUS MOST RECENT
Date of State Police clearance
Date of Child Abuse clearance
Date of mandated reporter training
Date of most recent physical exam
Date Mantoux test read
Results of Mantoux test (check one)
POS NEG POS NEG POS NEG
Signature of physician/CRNP/PA
Yes No Yes No Yes No
Proof of qualifications on file
Yes No Yes No Yes No
Qualifications: List the highest level
of education obtained and the
years of experience.
Two written non-family references
Yes No Yes No Yes No
Date of pediatric first aid training
Date of pediatric CPR
Required six hours of annual training
Date of health and safety training
PREVIOUS MOST RECENT PREVIOUS MOST RECENT PREVIOUS MOST RECENT
Date of staff evaluations
Date of emergency plan training
Date of fire safety training
Date of water safety training
CD 340 11/19
(CHECK ONE)
Director GS
AGS AIDE
Primary Secondary
