COVERED PERSONNEL SPREADSHEET Enter Agency Legal Name Below: Enter Contract Number Below Date Below Name of Preparer Below Required Required Required for Covered Personnel's name appears on for all for all all A1 Required for all most recent Fingerprint Status Letter Covered Covered Covered A1 Covered issued to contractor via e-mail. Personnel. Personnel. Personnel Personnel Fingerprint- National Based Job Child Court Record Sex National and Title/Duties Last four Protection Searches for LEA Date of Offender State Check of Covered numbers Service records in all Covered Personnel's Covered Personnel's Birth of Registry completed Personnel. of SS# of Checks for jurisdictions Last Name First Name Covered Check for all and Assure that Covered all states lived in last five Personnel States lived evaluated CEO is listed Personnel lived in last years? on in last five through five years? Yes or No spreadsheet years? DCS? Yes or No
COVERED PERSONNEL SPREADSHEET Enter Agency Legal Name Below: Enter Contract Number Below Date Below Name of Preparer Below Covered Personnel's name appears on most recent Fingerprint Status Letter issued to contractor via e-mail. Required for all Covered Personnel. Required for all Covered Personnel. Required for all A1 Covered Personnel Required for all A1 Covered Personnel Covered Personnel's Last Name Covered Personnel's First Name Date of Birth of Covered Personnel Last four numbers of SS# of Covered Personnel Job Title/Duties of Covered Personnel. Assure that CEO is listed on spreadsheet Child Protection Service Checks for all states lived in last five years? National Sex Offender Registry Check for all States lived in last five years? Fingerprint- Based National and State Check completed and evaluated through DCS? Yes or No Court Record Searches for LEA records in all jurisdictions lived in last five years? Yes or No