ADDITIONAL STAFF MEMBER CHANGE INFORMATION FACILITY NAME: – Complete this section if change information is being reported. (i.e., new staff, deleting an existing staff, staff position changes). Page 1 must be submitted with page 2. Type of Change Transferring from another facility in Maryland? Name of Add Delete change No Yes Name and County of previous facility Date left Staff Date Date (please explain, i.e. hours, position, age of group) Member PLEASE NOTE: Notification of New Staff An operator shall: – Within 5 working days of adding a new employee or member, provide to the Office: Written notification of the individual’s addition to the center staff; Information about the individual’s work assignment; and A signed and notarized permission to examine records of abuse and neglect of children and adults for information about the individual; and Within 15 working days of adding the new employee or staff member, provide to the office: If applicable, documentation that the individual meets the requirements of this chapter for the assignment, unless documentation already is on file in the office, and If the individual is paid by the center operator, proof of compliance with the laws and regulations pertaining to criminal background checks. Signature of Operator or Director________________________________________ Date ________________________ OCC 1203 Revised 3/16 All previous editions are obsolete Page 2 of 2 – –
ADDITIONAL STAFF MEMBER CHANGE INFORMATION – FACILITY NAME: Complete this section if change information is being reported. (i.e., new staff, deleting an existing staff, staff position changes). Page 1 must be submitted with page 2. Name of Staff Member Type of Change Transferring from another facility in Maryland? Add Date Delete Date change (please explain, i.e. hours, position, age of group) No Yes Name and County of previous facility Date left PLEASE NOTE: Notification of New Staff – An operator shall: Within 5 working days of adding a new employee or member, provide to the Office: Written notification of the individual’s addition to the center staff; Information about the individual’s work assignment; and A signed and notarized permission to examine records of abuse and neglect of children and adults for information about the individual; and Within 15 working days of adding the new employee or staff member, provide to the office: If applicable, documentation that the individual meets the requirements of this chapter for the assignment, unless documentation already is on file in the office, and If the individual is paid by the center operator, proof of compliance with the laws and regulations pertaining to criminal background checks. Signature of Operator or Director________________________________________ Date ________________________ OCC 1203 – Revised 3/16 – All previous editions are obsolete Page 2 of 2