STAFF FILE CHECKLIST

Name of Employee ______________ Date of Employment _____

The following items must be present in each staff members personnel file except for items marked () which are only required for centers meeting voluntary enhanced standards

iD

Date ReceivedCompleted

D Employment Application

0 Initial Medical Report

TB Test Results

D Annual Health Questionnaire

0 Emergency Information on Staff

Item

0 Documentation of Orientation

D Documentation of Inservice Training

0 Documentation of CPRFirst Aid Certification (if applicable)

i

0 Documentation of Playground Safety Training (if applicable)

CI Documentation of BSAC training (if applicable)

D Criminal Records Check Qualification Letter or copies of submitted documents

CI Credential Verification or Education Equivalency Information

D Annual Staff Development Plan

D Annual Staff Evaluations

CI Documentation of Job Description Receipt

0 Documentation of Operational and Personnel Policy Receipt

REV 8192

Application for Employment (Fully complete both sides offonn)

Date of Application Please Print Social Security Number Last Name First Name Middle Name

Address (street number and name) City COWlty

State Zip Code Phone (home or where you can be reached) Business Phone

Position Applied For _________________

_Date of Birth =_(_--=__=)_ N C Drivers License Number_______________ (month) -u v-

Have you ever been convicted of breaking a law other than a minor traffic violation (The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying)D YES D NO If yes give the date and explain fully on an a~ditional piece of paper if more space is needed

Education Circle the highest grade 1 2 3 4 5 6 7 89 10 I I 12 GED College 2 3 4

completed

I

Schools Name and Location Dates Attended Coursed of Study OegreelDiploma High School

to

f

College or

University

to

to

to

to

to

Graduate or

Professional

to

to

Educational

Vocational

Schools etc

to

to

to

to

Child care training you have completed in the last three years (such as first aid CPR COA etc)shy

References List the names addresses and phone numbers of two people we may contact as references

V

Work History (List child careearly childhood experience first)

J

j

Curreu or last Employer Address i

Job Title Supcnisors Name INo Supervised by you

DIIte Employed (molyr) IStrtiag Salary S Per

Eliding Salary [ Reason for leaving S Per

IMay we contact employer yes 00

Date Separated (molyr) Duties

FilII Time Years Mouths

Part Time Years Mooths

If part time nomber of honrs pcr week

Correot or Last Employer Address

Job Title Superrisors Name INo Supervised by you

DIIte Employed (molyr) IStartiaK Salary S Per

Endlol Salary IReason for leaving S Per

IMay we contact employer yes 00

Date Separated (moIyr) Duties

FilII Time Years Moutlls

Part Time Years Mouths

Ifpart time nomber of hours per week

Correot or Lst Employer Address

Job Title Supervisor s Name INo Supervised by you

Date Employed (moyr) IStarting Salary$ Per

Ending Salary IReason for leaving$ Per

IMay we contact employer I yes no

Date Separated (molyr) Duties

Full Time Years Months

Part Time Years Months

If part time number ofhours per week

I certify that I have gtven true accurate and complete Information on this form to the best ofmy knowledge In the event confirmation IS needed in connection with my work I authorize educational institutions associations registration and licensing boards and others to furnish whatever detail is available concerning my qualifications I authorize investigations ofall statements made in this application and understand that false infonnation ofdocumentation or a failure to disclose relevant infonnation may be grounds for rejection ofmy application disciplinary action or dismissal ifI am employed and (or) criminal actionl further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures an given to meet position qualifications

Signature ofApplicant______________________~Date__________

oeD 0107 1299

Tuberculin (TB) Test All staff members are required to have a negative test result before coming in to contact with children Volunteers and Substitutes present more than once per week must also have evidence ofa negative test

NAME Last First Middle

HOME ADDRESS

TELEPHONE NUMBER

Evidence of tuberculin test

Type of test Date given

Results a Negative a Positive

Comments rmiddot

Signature ofAuthorized Health Professional

Address

Phone Number

c

Form W-9 (Rev January 2003)

Department of the Treasury Intemal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester Do not se j to the IRS

N ltlJ 01 OJ a c 0

egt IIog ~

Name

Business name if different from above

o IndividuaV o Corporatiorl o Partnership o Other - 1 E)(empt from backup

Check appropriate box Sole proprietor wilhholdklg t)

o 2 Requesters name and address (optionaO Address (rumber street and apt or suite no)

c f~1

i City state and ZIP code I) 4gt 0

C) Ust account number(s) here (optlonaO ltll

ltll (J)

1FTiII Taxpayer Identification Number (TIN)

ISocia security number

However for a resident alien sole proprietor or disregarded entity see the Part I instructions on Enter your llN in the appropriate box For individuals this is your social security number (SSN)

I + I plusmn page 3 For other entities it Is your employer identification number (EIN) If you do not have a number see How to get a TIN on page 3 or

Note If the account s in more than one name see the chait on page 4 for guidelines on whose number to enter

Certification

Under penalties of perjury I certify that

1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me) and

2 I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and

3 I am a US person Onciuding a Us resident alien)

Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retiremfmt arrangement (IRA) and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN (See the instructions on page 4)

Sign I Signature of Here US person Ii Oate Ii

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report for example income paid to you real estate transactions mortgage Interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA

US person Use Form W-g only if you are a US person (Including a resident alien) to prollide your correct TIN to the person requesting it (the requester) and when applicable to

1 Certify that the TIN you are gilling Is correct (or you are waiting for a number to be issued)

2 Certify that you are not subject to backup withholding or

3 Claim exemption from backup withholding if you are a US exempt payee

Note If a requester gives you 8 form other than Form W-g to request your TIN you must use the requesters form jf It is substantially similar to this Form W-9

Foreign person If you are a foreign person use the appropriate Form w-e (see Pub 515 Withholding of Tax on Nonresident Aliens and Foreign Entities)

Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate US tax on certain types of income However most tax t~lt3aties contain a provision known as a saving clause Exceptions specified In the sailing clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a US reSident alien for tax purposes

if you are a US resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from US tax on certain types of Income you must attach a statement that specifies the following five items

1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident allen

2 The treaty article addressing the income 3 The article number (or location) In the tax treaty that

contains the salling clause and its exceptions

4 The type and amount of income that qualifies for the exemption from tax

5 Sufficient facts to justify the exemption from tax under the terms of the treaty-article

Cat No 10231X

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

REV 8192

Application for Employment (Fully complete both sides offonn)

Date of Application Please Print Social Security Number Last Name First Name Middle Name

Address (street number and name) City COWlty

State Zip Code Phone (home or where you can be reached) Business Phone

Position Applied For _________________

_Date of Birth =_(_--=__=)_ N C Drivers License Number_______________ (month) -u v-

Have you ever been convicted of breaking a law other than a minor traffic violation (The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying)D YES D NO If yes give the date and explain fully on an a~ditional piece of paper if more space is needed

Education Circle the highest grade 1 2 3 4 5 6 7 89 10 I I 12 GED College 2 3 4

completed

I

Schools Name and Location Dates Attended Coursed of Study OegreelDiploma High School

to

f

College or

University

to

to

to

to

to

Graduate or

Professional

to

to

Educational

Vocational

Schools etc

to

to

to

to

Child care training you have completed in the last three years (such as first aid CPR COA etc)shy

References List the names addresses and phone numbers of two people we may contact as references

V

Work History (List child careearly childhood experience first)

J

j

Curreu or last Employer Address i

Job Title Supcnisors Name INo Supervised by you

DIIte Employed (molyr) IStrtiag Salary S Per

Eliding Salary [ Reason for leaving S Per

IMay we contact employer yes 00

Date Separated (molyr) Duties

FilII Time Years Mouths

Part Time Years Mooths

If part time nomber of honrs pcr week

Correot or Last Employer Address

Job Title Superrisors Name INo Supervised by you

DIIte Employed (molyr) IStartiaK Salary S Per

Endlol Salary IReason for leaving S Per

IMay we contact employer yes 00

Date Separated (moIyr) Duties

FilII Time Years Moutlls

Part Time Years Mouths

Ifpart time nomber of hours per week

Correot or Lst Employer Address

Job Title Supervisor s Name INo Supervised by you

Date Employed (moyr) IStarting Salary$ Per

Ending Salary IReason for leaving$ Per

IMay we contact employer I yes no

Date Separated (molyr) Duties

Full Time Years Months

Part Time Years Months

If part time number ofhours per week

I certify that I have gtven true accurate and complete Information on this form to the best ofmy knowledge In the event confirmation IS needed in connection with my work I authorize educational institutions associations registration and licensing boards and others to furnish whatever detail is available concerning my qualifications I authorize investigations ofall statements made in this application and understand that false infonnation ofdocumentation or a failure to disclose relevant infonnation may be grounds for rejection ofmy application disciplinary action or dismissal ifI am employed and (or) criminal actionl further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures an given to meet position qualifications

Signature ofApplicant______________________~Date__________

oeD 0107 1299

Tuberculin (TB) Test All staff members are required to have a negative test result before coming in to contact with children Volunteers and Substitutes present more than once per week must also have evidence ofa negative test

NAME Last First Middle

HOME ADDRESS

TELEPHONE NUMBER

Evidence of tuberculin test

Type of test Date given

Results a Negative a Positive

Comments rmiddot

Signature ofAuthorized Health Professional

Address

Phone Number

c

Form W-9 (Rev January 2003)

Department of the Treasury Intemal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester Do not se j to the IRS

N ltlJ 01 OJ a c 0

egt IIog ~

Name

Business name if different from above

o IndividuaV o Corporatiorl o Partnership o Other - 1 E)(empt from backup

Check appropriate box Sole proprietor wilhholdklg t)

o 2 Requesters name and address (optionaO Address (rumber street and apt or suite no)

c f~1

i City state and ZIP code I) 4gt 0

C) Ust account number(s) here (optlonaO ltll

ltll (J)

1FTiII Taxpayer Identification Number (TIN)

ISocia security number

However for a resident alien sole proprietor or disregarded entity see the Part I instructions on Enter your llN in the appropriate box For individuals this is your social security number (SSN)

I + I plusmn page 3 For other entities it Is your employer identification number (EIN) If you do not have a number see How to get a TIN on page 3 or

Note If the account s in more than one name see the chait on page 4 for guidelines on whose number to enter

Certification

Under penalties of perjury I certify that

1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me) and

2 I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and

3 I am a US person Onciuding a Us resident alien)

Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retiremfmt arrangement (IRA) and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN (See the instructions on page 4)

Sign I Signature of Here US person Ii Oate Ii

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report for example income paid to you real estate transactions mortgage Interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA

US person Use Form W-g only if you are a US person (Including a resident alien) to prollide your correct TIN to the person requesting it (the requester) and when applicable to

1 Certify that the TIN you are gilling Is correct (or you are waiting for a number to be issued)

2 Certify that you are not subject to backup withholding or

3 Claim exemption from backup withholding if you are a US exempt payee

Note If a requester gives you 8 form other than Form W-g to request your TIN you must use the requesters form jf It is substantially similar to this Form W-9

Foreign person If you are a foreign person use the appropriate Form w-e (see Pub 515 Withholding of Tax on Nonresident Aliens and Foreign Entities)

Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate US tax on certain types of income However most tax t~lt3aties contain a provision known as a saving clause Exceptions specified In the sailing clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a US reSident alien for tax purposes

if you are a US resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from US tax on certain types of Income you must attach a statement that specifies the following five items

1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident allen

2 The treaty article addressing the income 3 The article number (or location) In the tax treaty that

contains the salling clause and its exceptions

4 The type and amount of income that qualifies for the exemption from tax

5 Sufficient facts to justify the exemption from tax under the terms of the treaty-article

Cat No 10231X

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

V

Work History (List child careearly childhood experience first)

J

j

Curreu or last Employer Address i

Job Title Supcnisors Name INo Supervised by you

DIIte Employed (molyr) IStrtiag Salary S Per

Eliding Salary [ Reason for leaving S Per

IMay we contact employer yes 00

Date Separated (molyr) Duties

FilII Time Years Mouths

Part Time Years Mooths

If part time nomber of honrs pcr week

Correot or Last Employer Address

Job Title Superrisors Name INo Supervised by you

DIIte Employed (molyr) IStartiaK Salary S Per

Endlol Salary IReason for leaving S Per

IMay we contact employer yes 00

Date Separated (moIyr) Duties

FilII Time Years Moutlls

Part Time Years Mouths

Ifpart time nomber of hours per week

Correot or Lst Employer Address

Job Title Supervisor s Name INo Supervised by you

Date Employed (moyr) IStarting Salary$ Per

Ending Salary IReason for leaving$ Per

IMay we contact employer I yes no

Date Separated (molyr) Duties

Full Time Years Months

Part Time Years Months

If part time number ofhours per week

I certify that I have gtven true accurate and complete Information on this form to the best ofmy knowledge In the event confirmation IS needed in connection with my work I authorize educational institutions associations registration and licensing boards and others to furnish whatever detail is available concerning my qualifications I authorize investigations ofall statements made in this application and understand that false infonnation ofdocumentation or a failure to disclose relevant infonnation may be grounds for rejection ofmy application disciplinary action or dismissal ifI am employed and (or) criminal actionl further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures an given to meet position qualifications

Signature ofApplicant______________________~Date__________

oeD 0107 1299

Tuberculin (TB) Test All staff members are required to have a negative test result before coming in to contact with children Volunteers and Substitutes present more than once per week must also have evidence ofa negative test

NAME Last First Middle

HOME ADDRESS

TELEPHONE NUMBER

Evidence of tuberculin test

Type of test Date given

Results a Negative a Positive

Comments rmiddot

Signature ofAuthorized Health Professional

Address

Phone Number

c

Form W-9 (Rev January 2003)

Department of the Treasury Intemal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester Do not se j to the IRS

N ltlJ 01 OJ a c 0

egt IIog ~

Name

Business name if different from above

o IndividuaV o Corporatiorl o Partnership o Other - 1 E)(empt from backup

Check appropriate box Sole proprietor wilhholdklg t)

o 2 Requesters name and address (optionaO Address (rumber street and apt or suite no)

c f~1

i City state and ZIP code I) 4gt 0

C) Ust account number(s) here (optlonaO ltll

ltll (J)

1FTiII Taxpayer Identification Number (TIN)

ISocia security number

However for a resident alien sole proprietor or disregarded entity see the Part I instructions on Enter your llN in the appropriate box For individuals this is your social security number (SSN)

I + I plusmn page 3 For other entities it Is your employer identification number (EIN) If you do not have a number see How to get a TIN on page 3 or

Note If the account s in more than one name see the chait on page 4 for guidelines on whose number to enter

Certification

Under penalties of perjury I certify that

1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me) and

2 I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and

3 I am a US person Onciuding a Us resident alien)

Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retiremfmt arrangement (IRA) and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN (See the instructions on page 4)

Sign I Signature of Here US person Ii Oate Ii

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report for example income paid to you real estate transactions mortgage Interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA

US person Use Form W-g only if you are a US person (Including a resident alien) to prollide your correct TIN to the person requesting it (the requester) and when applicable to

1 Certify that the TIN you are gilling Is correct (or you are waiting for a number to be issued)

2 Certify that you are not subject to backup withholding or

3 Claim exemption from backup withholding if you are a US exempt payee

Note If a requester gives you 8 form other than Form W-g to request your TIN you must use the requesters form jf It is substantially similar to this Form W-9

Foreign person If you are a foreign person use the appropriate Form w-e (see Pub 515 Withholding of Tax on Nonresident Aliens and Foreign Entities)

Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate US tax on certain types of income However most tax t~lt3aties contain a provision known as a saving clause Exceptions specified In the sailing clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a US reSident alien for tax purposes

if you are a US resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from US tax on certain types of Income you must attach a statement that specifies the following five items

1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident allen

2 The treaty article addressing the income 3 The article number (or location) In the tax treaty that

contains the salling clause and its exceptions

4 The type and amount of income that qualifies for the exemption from tax

5 Sufficient facts to justify the exemption from tax under the terms of the treaty-article

Cat No 10231X

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

oeD 0107 1299

Tuberculin (TB) Test All staff members are required to have a negative test result before coming in to contact with children Volunteers and Substitutes present more than once per week must also have evidence ofa negative test

NAME Last First Middle

HOME ADDRESS

TELEPHONE NUMBER

Evidence of tuberculin test

Type of test Date given

Results a Negative a Positive

Comments rmiddot

Signature ofAuthorized Health Professional

Address

Phone Number

c

Form W-9 (Rev January 2003)

Department of the Treasury Intemal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester Do not se j to the IRS

N ltlJ 01 OJ a c 0

egt IIog ~

Name

Business name if different from above

o IndividuaV o Corporatiorl o Partnership o Other - 1 E)(empt from backup

Check appropriate box Sole proprietor wilhholdklg t)

o 2 Requesters name and address (optionaO Address (rumber street and apt or suite no)

c f~1

i City state and ZIP code I) 4gt 0

C) Ust account number(s) here (optlonaO ltll

ltll (J)

1FTiII Taxpayer Identification Number (TIN)

ISocia security number

However for a resident alien sole proprietor or disregarded entity see the Part I instructions on Enter your llN in the appropriate box For individuals this is your social security number (SSN)

I + I plusmn page 3 For other entities it Is your employer identification number (EIN) If you do not have a number see How to get a TIN on page 3 or

Note If the account s in more than one name see the chait on page 4 for guidelines on whose number to enter

Certification

Under penalties of perjury I certify that

1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me) and

2 I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and

3 I am a US person Onciuding a Us resident alien)

Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retiremfmt arrangement (IRA) and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN (See the instructions on page 4)

Sign I Signature of Here US person Ii Oate Ii

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report for example income paid to you real estate transactions mortgage Interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA

US person Use Form W-g only if you are a US person (Including a resident alien) to prollide your correct TIN to the person requesting it (the requester) and when applicable to

1 Certify that the TIN you are gilling Is correct (or you are waiting for a number to be issued)

2 Certify that you are not subject to backup withholding or

3 Claim exemption from backup withholding if you are a US exempt payee

Note If a requester gives you 8 form other than Form W-g to request your TIN you must use the requesters form jf It is substantially similar to this Form W-9

Foreign person If you are a foreign person use the appropriate Form w-e (see Pub 515 Withholding of Tax on Nonresident Aliens and Foreign Entities)

Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate US tax on certain types of income However most tax t~lt3aties contain a provision known as a saving clause Exceptions specified In the sailing clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a US reSident alien for tax purposes

if you are a US resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from US tax on certain types of Income you must attach a statement that specifies the following five items

1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident allen

2 The treaty article addressing the income 3 The article number (or location) In the tax treaty that

contains the salling clause and its exceptions

4 The type and amount of income that qualifies for the exemption from tax

5 Sufficient facts to justify the exemption from tax under the terms of the treaty-article

Cat No 10231X

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

Form W-9 (Rev January 2003)

Department of the Treasury Intemal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester Do not se j to the IRS

N ltlJ 01 OJ a c 0

egt IIog ~

Name

Business name if different from above

o IndividuaV o Corporatiorl o Partnership o Other - 1 E)(empt from backup

Check appropriate box Sole proprietor wilhholdklg t)

o 2 Requesters name and address (optionaO Address (rumber street and apt or suite no)

c f~1

i City state and ZIP code I) 4gt 0

C) Ust account number(s) here (optlonaO ltll

ltll (J)

1FTiII Taxpayer Identification Number (TIN)

ISocia security number

However for a resident alien sole proprietor or disregarded entity see the Part I instructions on Enter your llN in the appropriate box For individuals this is your social security number (SSN)

I + I plusmn page 3 For other entities it Is your employer identification number (EIN) If you do not have a number see How to get a TIN on page 3 or

Note If the account s in more than one name see the chait on page 4 for guidelines on whose number to enter

Certification

Under penalties of perjury I certify that

1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me) and

2 I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and

3 I am a US person Onciuding a Us resident alien)

Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retiremfmt arrangement (IRA) and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN (See the instructions on page 4)

Sign I Signature of Here US person Ii Oate Ii

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report for example income paid to you real estate transactions mortgage Interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA

US person Use Form W-g only if you are a US person (Including a resident alien) to prollide your correct TIN to the person requesting it (the requester) and when applicable to

1 Certify that the TIN you are gilling Is correct (or you are waiting for a number to be issued)

2 Certify that you are not subject to backup withholding or

3 Claim exemption from backup withholding if you are a US exempt payee

Note If a requester gives you 8 form other than Form W-g to request your TIN you must use the requesters form jf It is substantially similar to this Form W-9

Foreign person If you are a foreign person use the appropriate Form w-e (see Pub 515 Withholding of Tax on Nonresident Aliens and Foreign Entities)

Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate US tax on certain types of income However most tax t~lt3aties contain a provision known as a saving clause Exceptions specified In the sailing clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a US reSident alien for tax purposes

if you are a US resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from US tax on certain types of Income you must attach a statement that specifies the following five items

1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident allen

2 The treaty article addressing the income 3 The article number (or location) In the tax treaty that

contains the salling clause and its exceptions

4 The type and amount of income that qualifies for the exemption from tax

5 Sufficient facts to justify the exemption from tax under the terms of the treaty-article

Cat No 10231X

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

DCD-0314

REV 1299

( Staff Health Questionnaire (To be completed by all staff substitutes and volunteers and placed m file once per year)

NAME Last First Middle

-

HOME ADDRESS

TELEPHONE NUMBER

HEALTHSTATIJS

1 I am in excellent mental and physical health and am free of communicable disease (Ifnot please explain)

2 1 take the following medications regularly (please explain)

This health statement is accurate to the best ofmy knowledge 1 will advise the director ifmy health status changes

Signature________________Date________

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

SAMPLE FORM EMERGENCY INFORMATION ON STAFF

To be (ompered and placed on file liir to employment

NAME______________________________________________________________________

ADDRESS_____________________________________________________________________

NA~reOFDOCTOR___________________________________ PHONE _____________~__________

HOSPlT AL PREFERENCE ___________________________ PHONE _______________________

NAMEOFDENTffiT ________________________________ PHONE ______________________

To avoid any adverse drug reaction during an emergency please list medications you are taking _________________

ALLERGIES ___________________________________________________________

BLOOD TYPE (if known) ___________________________________________________

LIST OPERATIONSHOSPITALIZATIONS WITHIN THE PAST YEAR__

LIST CHRONIC MEDICAL PROBLEMS REQUIRING A DOCTORS CARE

EMERGENCY CONTACf PERSONS

NAME________________________________________ RELATIONSHIP___________

ADDRESS______________________________________________________

HOME PHONE ________________________ BUSINESS PHONE _________

NAME__________________________ RELATIONSillP__________

ADDRESS_________________________________________

HOME PHONE ___________________________________ BUSINESS PHONE _______________

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

~~m~ _____~~_________

cC1jgmr-edJ ftmidPs d mlWSt meet minim~m rrzqlliremems must have2 semesteY hOllltS in feECD

TetuhrT CQumed in lltlftios all ffllUJst meet minimum requIrements 50 must h(JJlleuro the NCECe or equivalent or 4 semester hours In ECfCD

~ TtiJtGchefb Ctrtn1ted in lTmilPs aiD must meet minimllm requirements 50 (fl1fItt have thE NCECC OfT equivalent or 4 semester hOlArs in tEaCD and 1 YUJI7 full time vuifjable early childhood experience

t1 T~r8rJeiS CdJ)JJJnte2J Dfd r~io$ ZtDI mfllst meet mUMmum ytUlMiremenffS 50 ml4st htPrV1l the NCECe or lWJuiwJient and 4 semester hours in ECfECD ~md 2 YUlf$ fldi tiU11e verifiable early childhood experience

MV Education Plan

ClOlmponent Enrolled Completed Comments High School orr CED NeECe EDU 111 NeEce EDU 112 ECECD Z semesmr hOlDrs ECECD 4 semester hours ECECD AAS degree ECECD BSBA degree Other

My Personal Goal Statement

5~c __________________________ Date ______

NORTH CAROLINA EDUCATION AND EQUIVALENCY FORM FOR CHILD CARE LEAD TEACHERS (See baclc of form for instructions)

This form only needs to be completed and submitted to the Division of Child Development ONCE Changes to any ofthe applicant or facility information should be submitted on a DCD0120 Change of I nformation form NOT a new DCD0013

lead Teacher form

A) Applicant Information Social Security - Legal Name Legal Maiden Name

Last First Middle Home Mailing Address State __ lip

Date of Birth Home Telephone If ( ) County of

B) Faciliy Information Date of Employment for lead Teacher PositioName of Facility

Mailing Address

Facility license Facility Telephone )

n in This Facility County

State Zip

FAX If )

C) Educational BackgrOWld check ALL that have been com~lete~ Attach official transcripts (NOT photocoPies student copies or grade rePO1s) for ALL completed

GED __High School Diploma AA1AAS BAIBS Program Major (s) School(s)

~ coursework certificates diplomas andor degrees MAIMS EdDIPhD

D) NC Earll Childhood Credential Coursework Information NC Early Childhood Credential (NCECC) course I Completed

(Check both course I Currently Enrolled

II if you completed EDU 119) Plan to Enroll Date

NC Early Childhood Credential (NCECC) course II Completed Currently Enrolled Plan to Enroll Dale Received NCECC certificate issued jointly by the Division of Child Development and the NC Community College System__Altach copy ofNeECC cerlfficate)

DO NOT COMPLETE SECTION EIF YOU COMPLETED SECTION 0 PROCEED TO SECTION F E) NC Early Childhood Credential Equivalency Options check ONE optIon only OPTIONS RECEIVE EQUIVALENCYLEmR ONLY 1 -- Request to test out of the Division of Child Development NCECC standardized equivalency test

Have successfully tested out of the Division of Child Develollfllent NCECC standardized equivalency test Attach copy of letter 2 Completed and currently actiJe__Child development early childhood human growth amp developmentlspecial education or child care credential(s) certificate that meets the following six criteria ) Nationally accredited and available in all 50 states 2) Comprehensive in scope which is inclusive of the following six areas child growth and development professionalism health and safety creation of appropriate environments that enhance physical emotional social and cognitive development developmentally appropriate learning activities and working with families 3) 120 clock (contact) hours of education andor training 4) Formal observation andor portfolio assessment 5) Standardized written assessment and 6) Individually earned (Attach copy ofcertificate) Applicants reQUesting to be assessed for opUons J6 must attach official transcrilts not Ihotocouies student copJes or grade relJOrtf for ALL comfleted coursewt dillomas certificates andor dearees received to meet these reguirements 3 Completed__ Early Childhood Certificate Diploma or AAS Degree from an accredited- Community College 4 Completed__ BSBA degree (or higher) in Early ChildhoodChild DevelopmentHuman Growth and Development (with or without ampKcertification) from an accredited institution of higher education 5 Completed__ BSBA degree (or higher) in lY area piUS 12 semester credit hours (sch) in the course of study of Early ChildhoodChild DevelopmentHuman Growth amp DevelopmentSpecial Education programs with at least 3 sch in Child Growth and Development from an accredited institution of higher education 6 __ Receipt of 12 sch in the course of study of Early ChildhoodChild DevelollfllentiHuman Growth amp DevelopmentISpecial Education programs with at least 3 sch in Child Growth and Development from an accredited institution of higher education Attach official transcripts (not photocopies student copies or grade reports) for All com(Aeted degrees andor coursework For all coursewOtt over 10 lars old to be eli9ible for this NCECC Iivalencv you must be currently enrolled in a degree program (Attach proof)

Accredited is defined lIS nationally recognized higher education regional certirlcation For higher education institutions outside of the United States the recognized system of the specified coontrys accreditation process will be accepted

F) This statement must be signed and dated by the applicant AND legal operator (or hislher legal representative) of this child care facility Both parties attest to the accuracy of the above information

Applicant Date

I Legal operator or legal representative of child care facility Date NOTE EMPLOYING FACILITY MUST RETAIN ACOpy OF THIS FORM IN THE lEAD TEACHERS PERSONNEL FILE

APPLICANT SHOULD ALSO RETAIN ACOPY OF THIS FORM FOR HISIHER FILE

Division ofChild Development Rev 6104 Page 1 on DeDOIB

10NCAC 3U 0707(a) Rev 106

DOCUMENTATION OF STAFF ORIENTATION

Name ofEmployee _____________ Date ofEmployment _____

Inteot of rule Each staff member hired 00 or after Jaouary 1 2006 who has contact with the children will receive a minimum ofl6 clod hours ofon-site orientation Within the first two weeks ofemployment leW employees must complete 6 clock bours oftraiDiog aod orientatioo io tbe first tbree topic areas listed below The remaining 10 clock hours oforientation must be completed within the first six weeks ofemployment This orientation must include but not be limited to the contact areas identified in the chart below

bullmiddot R i middotmiddotmiddotilt middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotii middot~~~f Tti~g~i~t bullbullbullbullbull H~lIrxmiddotI bullbull gtltb

imiddot middot(slsnarnte~tri~middotmiddot -Cc gt Imiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot~I~middot bull~ Recognizing symptoms of child abuseneglect and the employees duty to report suspected abuseneglect (within the first two weeks of employment) Review ofthe centers operational policies andor parent handbook including the centers safe sleep policy for infants (witbio the first two weeks ofemploymeDt) Review ofadequate supervision ofchildren (within the first two weeks ofemploymeot) Maintaining a safe and healthy environment

Review ofthe child care licensing law regulations and Child Care Handbook Review of the role ofstate and local government agencies their effect on the center their availability as a resource and the individual staff responsibilities to representatives of state and local government agencies Observation of center operations

Review of the centers purpose and goals

Review of the individual job-specific duties and responsibilities andjob description Overview ofEnhanced Standards and Rated License Requirements

Review ofthe centers personnel policies

Other

Other

I haw provided training in the topics listed above

Signature ofDirector Date

I bave received training in the topics listed above

Signature ofEmployee Date

DCD-0049 Rev OlIOS

NOTICE CIllLD CARE PROVIDER MANDATORY CRIMINAL mSTORYCHECK

North Carolina law requires that a criminal history check be conducted on all persons who provide child care in a licensed or registered child care facility and all persons providing child care in nonlicensed child care homes or facilities that receive state or federal funds

Criminal history includes county state and federal convictions or pending indictments of any of the following crimes the following Articles of Chapter 14 of the General Statutes Article 6 Homicide Article 7A Rape and Kindred Offenses Article 8 Assaults Article 10 Kidnapping and Abduction Article 13 Malicious lnjury or Damage by Use ofExplosive or Incendiary Device or Material Article 26 Offenses Against Public Morality and Decency~ Article 27 Prostitution Article 39 Protection of Minors Article 40 Protection ofthe Family and Article 59 Public Intoxication violation ofthe North Carolina Controlled Substances Act Article 5 of Chapter 90 of the General Statutes and alcohol-related offenses such as sale to underage persons in violation of GS 18B-302 or driving while impaired in violation ofGS 20-1381 thrrugh GS 20-1385 or similar crimes under federal law or under the laws of other states Your fingerprints will be used to check the criminal history records ofthe State Bureau ofInvestigation (SBI) and the Federal Bureau of Investigation (FBI)

If it is determined based on your criminal history that you are unfit to have responsibility for the safety and well-being ofchildren you shall have the opportunity to complete or challenge the accuracy of the information contained in the SBI or FBI identification records

Ifyou disagree with the determination of the North Carolina Department of Health and Human Services on your fitness to provide child care you may file a civil lawsuit in the district court in the county where you live

Any child care provider who intentionally falsifies any information required to be furnished to conduct the criminal history shalt be guilty of a Class 2 misdemeanor

PRIOR CONVICTIONIPENDING INDICTMENT STATEMENT

I swear under penalty ofperjury that I have - have not __gt been convicted ofa crime nor have any

pending indictments other than a minor traffic violation Ifl have been convicted ofa crime or have pending

indictments I understand that my employment is conditional pending approval from the Division ofChild

Development I also understand that I may submit to the Division ofChild Development additional information

concerning the conviction or pending indictment that could be used by the Division in making the determination

ofmy qualification for employment The Division may consider the following in making their decision length of

time since conviction nature ofthe crime circumstances surrounding the commission ofthe offense or offenses

evidence ofrehabilitation number ofprior offimses and age ofthe individual at the time ofoccwrence

Signature Printed Name Date

Maintain This Form in Employee Personnel File Only (Do Not Mail) Division ofChild Development ( crcmiddotbasic2(05)

DCD-0048 I~ 5100

AUTHORITY F-ORRELEASE )F INF-ORMATION (For Fingerprint Card Submission)

I alaquothoriz~ the North CarHna Denartmootf lust-roe throoiZh the State Bur~alaquo[Inv~i1atron Division (f Criminal Information to perform a fingerprint search ofthe States criminal history record file andor the Fedc-al BY~u i)f Investiiratron fi)[ a national criminal historY reoorlti ltheck in oonneetioo with mv fitness to be a child care providerlemployee or other household member ufa child care pmgram regulated by the Devartment-f Health and Human Services (DHHS) Division -f Child Development vursuant t- NCGS 114-195 aOO110-902

Last Name First Middle Maiden

(Print or Type)

Social Securitv Number Dare-f Birth Sex Race

I laquonderstand that the North Car(JUna State Bureau (Jf lnvestiiratkm Div4si(Jn (Jf Crminallnfonnation and its officials and employees shaH not be held legally accountable in any way for providing this information to DHHS Division ofChild DevcJooment and I herebv release said airCflCV and oersons from anv and aU liability which may be incurred as a result offurnishing such information I further understand that DHHS Division (Jf ChHd Deveiooment ltannot rdease the results ofthis criminal historv recoru cl1eck to me

Signature ofPerson lltientified Above Date

Ifperson identified above is under age 18 parental consent is also cequested

01-142-00

To Be Submitted To The Division Of Child Development With The Local Cdmina) RistoI) Record Chec~ Identifying Information Sbeet And Completed Fingerprint Card(s)

FOR DCD STAFP otllY Complete if FBI check Required

J if Cardamp Submitted

PLEASE DO NOT RETYPE FORM

Department of Health and Human Services (DHHS) Criminal Record Check Unit Checklist

For each criminal record check you submit to DHHS please make sure you complete this checklist and staple it to

the applicants employee file at the facility Do not send it to DHHS This will help ensure all paperwork is complete and accurate as well as assist your consultant during visits to your facility

Applicants Name _____________ Date ofHire _______

Date Submitted to Raleigh __________

LOCAL HISTORY (must be submitted for every applicant) __ Included with packet __ From the clerk of courts office in the county ofapplicants residence __ Less than 90 days old __ Is the original with a certified seal (no photocopies) ___ Name on the local is correct and is exactly the same as shown on the bubble sheet and fingerprint card

BLUE BUBBLE SHEET -DeD 0050 (must be submitted for every applicant) __ Included with packet __ It is the new blue bubble sheet (not the old green sheets) __ It is the original (no photocopies) and it is not torn folded or mutilated in any way __ It is filled out completely (front and back) and with a 2 pencil __ A Division ofChild Development ID has been filled out in Box 11 __ The Authority For Release is signed in pen on the back of the form __ Name on the bubble sheet and release is correct and is exactly the same as shown on the local amp

fingerprint card

FINGERPRINT CARDS (to be submitted for new applicants or applicants qualified over a year ago) __ Included with packet for new applkantsiapplicants qualified over a year ago at another facility __ Correct type of card (FD 258) __ All personal data including signature has been completed __ Fingerprints were rolled by a trained professional (local law enforcement agency) __ Only one (1) card has been submitted

Name on card is correct and is exactly the same as shown on the local and bubble sheet

All required paperwork was submitted to Raleigh within 8 days of hire Child Care Provider Mandatory Criminal History Check Form (DCD-0049) has not been submitted Initials ofperson who submitted the paperwork

SAMPLE FORM

RECORD OF INSERVICE TRAINING

Name ofEmployee Date of Employment Record for training year beginning ______

Training Hours Required Training Hours Brought Forward __________

Training Date Number of Topic Instructor Sponsor Training Hours

Received

(attach documentation ofattendance agendas etc for each training event)

DCD-0049 Rev OlIOS

NOTICE CIllLD CARE PROVIDER MANDATORY CRIMINAL mSTORYCHECK

North Carolina law requires that a criminal history check be conducted on all persons who provide child care in a licensed or registered child care facility and all persons providing child care in nonlicensed child care homes or facilities that receive state or federal funds

Criminal history includes county state and federal convictions or pending indictments of any of the following crimes the following Articles of Chapter 14 of the General Statutes Article 6 Homicide Article 7A Rape and Kindred Offenses Article 8 Assaults Article 10 Kidnapping and Abduction Article 13 Malicious lnjury or Damage by Use ofExplosive or Incendiary Device or Material Article 26 Offenses Against Public Morality and Decency~ Article 27 Prostitution Article 39 Protection of Minors Article 40 Protection ofthe Family and Article 59 Public Intoxication violation ofthe North Carolina Controlled Substances Act Article 5 of Chapter 90 of the General Statutes and alcohol-related offenses such as sale to underage persons in violation of GS 18B-302 or driving while impaired in violation ofGS 20-1381 thrrugh GS 20-1385 or similar crimes under federal law or under the laws of other states Your fingerprints will be used to check the criminal history records ofthe State Bureau ofInvestigation (SBI) and the Federal Bureau of Investigation (FBI)

If it is determined based on your criminal history that you are unfit to have responsibility for the safety and well-being ofchildren you shall have the opportunity to complete or challenge the accuracy of the information contained in the SBI or FBI identification records

Ifyou disagree with the determination of the North Carolina Department of Health and Human Services on your fitness to provide child care you may file a civil lawsuit in the district court in the county where you live

Any child care provider who intentionally falsifies any information required to be furnished to conduct the criminal history shalt be guilty of a Class 2 misdemeanor

PRIOR CONVICTIONIPENDING INDICTMENT STATEMENT

I swear under penalty ofperjury that I have - have not __gt been convicted ofa crime nor have any

pending indictments other than a minor traffic violation Ifl have been convicted ofa crime or have pending

indictments I understand that my employment is conditional pending approval from the Division ofChild

Development I also understand that I may submit to the Division ofChild Development additional information

concerning the conviction or pending indictment that could be used by the Division in making the determination

ofmy qualification for employment The Division may consider the following in making their decision length of

time since conviction nature ofthe crime circumstances surrounding the commission ofthe offense or offenses

evidence ofrehabilitation number ofprior offimses and age ofthe individual at the time ofoccwrence

Signature Printed Name Date

Maintain This Form in Employee Personnel File Only (Do Not Mail) Division ofChild Development ( crcmiddotbasic2(05)

DCD-0048 I~ 5100

AUTHORITY F-ORRELEASE )F INF-ORMATION (For Fingerprint Card Submission)

I alaquothoriz~ the North CarHna Denartmootf lust-roe throoiZh the State Bur~alaquo[Inv~i1atron Division (f Criminal Information to perform a fingerprint search ofthe States criminal history record file andor the Fedc-al BY~u i)f Investiiratron fi)[ a national criminal historY reoorlti ltheck in oonneetioo with mv fitness to be a child care providerlemployee or other household member ufa child care pmgram regulated by the Devartment-f Health and Human Services (DHHS) Division -f Child Development vursuant t- NCGS 114-195 aOO110-902

Last Name First Middle Maiden

(Print or Type)

Social Securitv Number Dare-f Birth Sex Race

I laquonderstand that the North Car(JUna State Bureau (Jf lnvestiiratkm Div4si(Jn (Jf Crminallnfonnation and its officials and employees shaH not be held legally accountable in any way for providing this information to DHHS Division ofChild DevcJooment and I herebv release said airCflCV and oersons from anv and aU liability which may be incurred as a result offurnishing such information I further understand that DHHS Division (Jf ChHd Deveiooment ltannot rdease the results ofthis criminal historv recoru cl1eck to me

Signature ofPerson lltientified Above Date

Ifperson identified above is under age 18 parental consent is also cequested

01-142-00

To Be Submitted To The Division Of Child Development With The Local Cdmina) RistoI) Record Chec~ Identifying Information Sbeet And Completed Fingerprint Card(s)

FOR DCD STAFP otllY Complete if FBI check Required

J if Cardamp Submitted

PLEASE DO NOT RETYPE FORM

Department of Health and Human Services (DHHS) Criminal Record Check Unit Checklist

For each criminal record check you submit to DHHS please make sure you complete this checklist and staple it to

the applicants employee file at the facility Do not send it to DHHS This will help ensure all paperwork is complete and accurate as well as assist your consultant during visits to your facility

Applicants Name _____________ Date ofHire _______

Date Submitted to Raleigh __________

LOCAL HISTORY (must be submitted for every applicant) __ Included with packet __ From the clerk of courts office in the county ofapplicants residence __ Less than 90 days old __ Is the original with a certified seal (no photocopies) ___ Name on the local is correct and is exactly the same as shown on the bubble sheet and fingerprint card

BLUE BUBBLE SHEET -DeD 0050 (must be submitted for every applicant) __ Included with packet __ It is the new blue bubble sheet (not the old green sheets) __ It is the original (no photocopies) and it is not torn folded or mutilated in any way __ It is filled out completely (front and back) and with a 2 pencil __ A Division ofChild Development ID has been filled out in Box 11 __ The Authority For Release is signed in pen on the back of the form __ Name on the bubble sheet and release is correct and is exactly the same as shown on the local amp

fingerprint card

FINGERPRINT CARDS (to be submitted for new applicants or applicants qualified over a year ago) __ Included with packet for new applkantsiapplicants qualified over a year ago at another facility __ Correct type of card (FD 258) __ All personal data including signature has been completed __ Fingerprints were rolled by a trained professional (local law enforcement agency) __ Only one (1) card has been submitted

Name on card is correct and is exactly the same as shown on the local and bubble sheet

All required paperwork was submitted to Raleigh within 8 days of hire Child Care Provider Mandatory Criminal History Check Form (DCD-0049) has not been submitted Initials ofperson who submitted the paperwork

SAMPLE FORM

RECORD OF INSERVICE TRAINING

Name ofEmployee Date of Employment Record for training year beginning ______

Training Hours Required Training Hours Brought Forward __________

Training Date Number of Topic Instructor Sponsor Training Hours

Received

(attach documentation ofattendance agendas etc for each training event)

DCD-0048 I~ 5100

AUTHORITY F-ORRELEASE )F INF-ORMATION (For Fingerprint Card Submission)

I alaquothoriz~ the North CarHna Denartmootf lust-roe throoiZh the State Bur~alaquo[Inv~i1atron Division (f Criminal Information to perform a fingerprint search ofthe States criminal history record file andor the Fedc-al BY~u i)f Investiiratron fi)[ a national criminal historY reoorlti ltheck in oonneetioo with mv fitness to be a child care providerlemployee or other household member ufa child care pmgram regulated by the Devartment-f Health and Human Services (DHHS) Division -f Child Development vursuant t- NCGS 114-195 aOO110-902

Last Name First Middle Maiden

(Print or Type)

Social Securitv Number Dare-f Birth Sex Race

I laquonderstand that the North Car(JUna State Bureau (Jf lnvestiiratkm Div4si(Jn (Jf Crminallnfonnation and its officials and employees shaH not be held legally accountable in any way for providing this information to DHHS Division ofChild DevcJooment and I herebv release said airCflCV and oersons from anv and aU liability which may be incurred as a result offurnishing such information I further understand that DHHS Division (Jf ChHd Deveiooment ltannot rdease the results ofthis criminal historv recoru cl1eck to me

Signature ofPerson lltientified Above Date

Ifperson identified above is under age 18 parental consent is also cequested

01-142-00

To Be Submitted To The Division Of Child Development With The Local Cdmina) RistoI) Record Chec~ Identifying Information Sbeet And Completed Fingerprint Card(s)

FOR DCD STAFP otllY Complete if FBI check Required

J if Cardamp Submitted

PLEASE DO NOT RETYPE FORM

Department of Health and Human Services (DHHS) Criminal Record Check Unit Checklist

For each criminal record check you submit to DHHS please make sure you complete this checklist and staple it to

the applicants employee file at the facility Do not send it to DHHS This will help ensure all paperwork is complete and accurate as well as assist your consultant during visits to your facility

Applicants Name _____________ Date ofHire _______

Date Submitted to Raleigh __________

LOCAL HISTORY (must be submitted for every applicant) __ Included with packet __ From the clerk of courts office in the county ofapplicants residence __ Less than 90 days old __ Is the original with a certified seal (no photocopies) ___ Name on the local is correct and is exactly the same as shown on the bubble sheet and fingerprint card

BLUE BUBBLE SHEET -DeD 0050 (must be submitted for every applicant) __ Included with packet __ It is the new blue bubble sheet (not the old green sheets) __ It is the original (no photocopies) and it is not torn folded or mutilated in any way __ It is filled out completely (front and back) and with a 2 pencil __ A Division ofChild Development ID has been filled out in Box 11 __ The Authority For Release is signed in pen on the back of the form __ Name on the bubble sheet and release is correct and is exactly the same as shown on the local amp

fingerprint card

FINGERPRINT CARDS (to be submitted for new applicants or applicants qualified over a year ago) __ Included with packet for new applkantsiapplicants qualified over a year ago at another facility __ Correct type of card (FD 258) __ All personal data including signature has been completed __ Fingerprints were rolled by a trained professional (local law enforcement agency) __ Only one (1) card has been submitted

Name on card is correct and is exactly the same as shown on the local and bubble sheet

All required paperwork was submitted to Raleigh within 8 days of hire Child Care Provider Mandatory Criminal History Check Form (DCD-0049) has not been submitted Initials ofperson who submitted the paperwork

SAMPLE FORM

RECORD OF INSERVICE TRAINING

Name ofEmployee Date of Employment Record for training year beginning ______

Training Hours Required Training Hours Brought Forward __________

Training Date Number of Topic Instructor Sponsor Training Hours

Received

(attach documentation ofattendance agendas etc for each training event)

Department of Health and Human Services (DHHS) Criminal Record Check Unit Checklist

For each criminal record check you submit to DHHS please make sure you complete this checklist and staple it to

the applicants employee file at the facility Do not send it to DHHS This will help ensure all paperwork is complete and accurate as well as assist your consultant during visits to your facility

Applicants Name _____________ Date ofHire _______

Date Submitted to Raleigh __________

LOCAL HISTORY (must be submitted for every applicant) __ Included with packet __ From the clerk of courts office in the county ofapplicants residence __ Less than 90 days old __ Is the original with a certified seal (no photocopies) ___ Name on the local is correct and is exactly the same as shown on the bubble sheet and fingerprint card

BLUE BUBBLE SHEET -DeD 0050 (must be submitted for every applicant) __ Included with packet __ It is the new blue bubble sheet (not the old green sheets) __ It is the original (no photocopies) and it is not torn folded or mutilated in any way __ It is filled out completely (front and back) and with a 2 pencil __ A Division ofChild Development ID has been filled out in Box 11 __ The Authority For Release is signed in pen on the back of the form __ Name on the bubble sheet and release is correct and is exactly the same as shown on the local amp

fingerprint card

FINGERPRINT CARDS (to be submitted for new applicants or applicants qualified over a year ago) __ Included with packet for new applkantsiapplicants qualified over a year ago at another facility __ Correct type of card (FD 258) __ All personal data including signature has been completed __ Fingerprints were rolled by a trained professional (local law enforcement agency) __ Only one (1) card has been submitted

Name on card is correct and is exactly the same as shown on the local and bubble sheet

All required paperwork was submitted to Raleigh within 8 days of hire Child Care Provider Mandatory Criminal History Check Form (DCD-0049) has not been submitted Initials ofperson who submitted the paperwork

SAMPLE FORM

RECORD OF INSERVICE TRAINING

Name ofEmployee Date of Employment Record for training year beginning ______

Training Hours Required Training Hours Brought Forward __________

Training Date Number of Topic Instructor Sponsor Training Hours

Received

(attach documentation ofattendance agendas etc for each training event)

SAMPLE FORM

RECORD OF INSERVICE TRAINING

Name ofEmployee Date of Employment Record for training year beginning ______

Training Hours Required Training Hours Brought Forward __________

Training Date Number of Topic Instructor Sponsor Training Hours

Received

(attach documentation ofattendance agendas etc for each training event)