Fillable Key Personnel Change Form (Commonwealth of Massachusetts)

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Key Personnel Change Form (Commonwealth of Massachusetts)

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The Key Personnel Change Form (Commonwealth of Massachusetts) form is 1 page long and contains:

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  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Massachusetts Department of Public Health
Bureau of Substance Addiction Services / Office of Quality Assurance and Licensing
KEY PERSONNEL CHANGE REPORTING FORM
Please fax completed form (no cover sheet is necessary) to QAAL secure fax: 617-624-5395
KEY PERSONNEL CHANGE
Please notify DPH/BSAS at least two weeks before a planned change or within two
business days of an unplanned change of the following key personnel (please check
one, and ATTACH RESUME of replacement/interim/
Reporter Name/Title: ________________________________
Program Name: ________________________________
License #: ______
Address: _____________________________________
If interim, please submit a projected timeline for replacing the staff member:
Medical Director, Program Director, Clinical Director Clinical Supervisor
Compliance Officer, Nurse Manager, Executive Director License Administrator,
Senior Management (Responsible for program oversight)
Name of Person Leaving: Last Day: ____________
Replacement (Permanent): Replacement Start Date: __________
E-mail address: Phone Number: _________________
OR
Interim Replacement (& Projected start date of replacement): __________________________
E-mail address: Phone Number: _________________
Resume of Replacement /Interim
If Interim Please Submit a Coverage Plan
Revised: 1/18
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Key Personnel Change Form (Commonwealth of Massachusetts)

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Completed 27 July 2020

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