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 Based Status Covered Covered Covered A1 Covered Letter issued to contractor via e-mail. Personnel. Personnel. Personnel Personnel Fingerprint- National Based Local Law Job Child Sex National and Enforcement Title/Duties Last four Protection Date of Offender State Check Check for all of Covered numbers Service Covered Personnel's Covered Personnel's Birth of Registry completed home Personnel. of SS# of Checks for Last Name First Name Covered Check for all and address(es) Assure that Covered all states Personnel States lived evaluated lived in last five CEO is listed Personnel lived in last on in last five through years? five years? spreadsheet years? DCS? Yes or No 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 Based 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 Local Law Enforcement Check for all home address(es) lived in last five years? Yes or No
Exhibit%201%20-%20Background%20Check%20and%20Sample%20Spreadsheet%20.%20NYTD%20Sample%20Contract.docx