Fillable REVIEW OF STAFF/VOLUNTEER RECORDS (California)

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REVIEW OF STAFF/VOLUNTEER RECORDS (California)

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
REVIEW OF STAFF/VOLUNTEER RECORDS
FACILITY NAME
LICENSE REPORT (LIC 809) DATE
FACILITY NUMBER
TYPE OF VISIT
PRELICENSING ANNUAL
COMPLAINT
FOLLOW-UP/POC
CASELOAD MANAGEMENT
ITEM
NUMBER
NAME
EMPLOYEE/VOLUNTEER
OFFICE REVIEW
CRIMINAL
RECORD
STATEMENT
DATE
EMPLOYED
POSITION
PERSONNEL
RECORD
OR JOB
APPLICATION
PHYSICIAN’S
REPORT
T.B.
TEST
FIRST
AID
CERTIFICATE
EDUCATION
VERIFICATION
EMPLOYEE
RIGHTS
MEDICAL
TRAINING
VERIFICATION
*
*
REQUIRED ONLY FOR STAFF (INCLUDING LICENSEES) CARING FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS
COMMENTS
FINGERPRINT
CLEARANCES/
EXEMPTIONS
CHILD
ABUSE
INDEX
LIC 859 (8/06) PERSONAL
LICENSING EVALUATOR SIGNATURE
➤
LICENSING EVALUATOR NAME (PRINT)
DATE
PAGE OF
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REVIEW OF STAFFVOLUNTEER RECORDS (California)

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Completed 15 January 2022

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