CHILD CARE EMPLOYEEHIRING, PROMOTION, OR …
CHILD CARE EMPLOYEE HIRING, PROMOTION, OR SEPARATION NOTIFICATION
Pursuant to Title 5A of the DCMR, Chapter 1, 131.1, this form must be completed and sent to the Division of Early Learning, Licensing and Compliance Unit for each newly hired (appointed) staff, staff promotion, or separation in your facility.
__________________________________________________________ Name of Facility
____________________________________ Director/Provider
STAFF MEMBER:
Name: ____________________________________________________________________________________
Date of Birth: _________________________________
Home Telephone: ______________________________
Cell Number: ________________________
Home Address: _____________________________________________________________________________
Title of Position: _______________________________ Date Hired: ________________________________
Brief Description of Duties: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Check each item below and attach all supporting documentation for each.
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Yes No Yes No
Current photograph Completed criminal background history check (Fieldprint) Completed child protection registry check (CPR) Health certificates Current resume Letters of reference Required degrees, credentials, or official transcripts Facility/employee orientation training (review of facility's policies and procedures, and employee duties and responsibilities) Professional development and earned continuing education units (see attached) Health and safety training requirements set forth in Section 139 (Staff Member Requirements: Professional Development) (see attached checklist)
810 First St. NE, 4th Floor, Washington, DC 20002 ? Phone: (202) 727-1839 TTY: 711 ? osse.
EDUCATION:
BA or higher: ______________________________________________
Name of Institution
________________
Date Awarded
Associates Degree: __________________________________________
Name of Institution
High School/GED: __________________________________________
Name of Institution
Montessori Certificate: ______________________________________
Name of Institution
CDA Credential: ___________________________________________
Name of Institution
________________
Date Awarded
________________
Date Awarded
________________
Date Awarded
________________
Date Awarded
PROFESSIONAL DEVELOPMENT COURSES (specify): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
SUPERVISED OCCUPATIONAL EXPERIENCE: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
_______________________________________________________ Signature and Title of Employer/Designee
____________________ Date
810 First St. NE, 4th Floor, Washington, DC 20002 ? Phone: (202) 727-1839 TTY: 711 ? osse.
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