ChildCare Aware of Kentucky – Kentucky's Child Care ...
Certified Family Child Care Staff/Family Record
Last Name ________________________
First Name ________________________
Role in Center Circle One: Provider Substitute Staff Family Member or Adult who Resides in the home
Date of Birth ________________________
Social Security Number ________________________ (last 4 digits)
Date of Hire or date of Re-Hire _________________
TB Skin Test ________________________ (record date checked/completed) (Required for all adults)
First Aid Certification ________________________ (expiration date)
CPR ________________________ (expiration date)
Work Schedule ________________________; i.e., Monday – Friday 9am-5pm
ECE Staff Record (condensed version) printed for review that reflects 9 hours of Cabinet approved training based on date of hire for the last full year worked and includes:
• 6 Hour Cabinet Approved Orientation Training Date _______________________
• Pediatric Abusive Head Trauma Training _______________________
Education Check one: ____ High school diploma ____ College Degree
____ Transcript with date of graduation from college or high school
____ GED
____ Current Commonwealth Child Care Credential
____ Current High School Student needs documentation verifying enrollment in school
Date of Annual driver’s history report if you transport children in your care:
____________
-----------------------
Results Registry _____________ Date of Fingerprint Scan ____________ First Day of Work/Residing in Home ________ Note: the fingerprint scan must be completed before the first day of work in the center
Completed Employment Authorization Form on File (Maintain a copy of this form for review)
____ DCC 500 On file for review (Maintain a copy of this form for review and upload into NBCP)
____ DCC 501 On file for review (Maintain this form for review and upload into NBCP)
Out of state background check needed Yes No (Maintain a copy of these checks and upload into NBCP)
For staff under the age of 18: Central Registry Check completed on ____________
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