Agency Name: CCS STAFF LISTING Chapter DHS 36 – Credentials/ Caregiver Misconduct Name Position Description Functions and Qualifications FTE % License Number Background Checks Dates Conducted (Last, MI) – Functions Minimum Qualifications Review 1 MH Professional Per DHS E = Employed – DHS within BID DOJ 2 Administrator 36.10 (c) (full or part time) – IBIS 3 Serv Director 1-8 last 4 (Mon/Yr) (Mon/Yr) – (Mon/Yr) 4 Serv Facilitator 1-14 C = Contracted yrs/ – 5 Services Array 1-21 – Any ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N ☐E ☐Y ☐C ☐N
Agency Name: CCS STAFF LISTING – Chapter DHS 36 Name (Last, MI) Position Description Credentials/ License Number Functions and Qualifications FTE % Caregiver Misconduct Background Checks – Dates Conducted Functions 1 – MH Professional 2 – Administrator 3 – Serv Director 4 – Serv Facilitator 5 – Services Array Minimum Qualifications Per DHS 36.10 (c) 1-8 1-14 1-21 Any E = Employed (full or part time) C = Contracted BID (Mon/Yr) DOJ (Mon/Yr) DHS IBIS (Mon/Yr) Review within last 4 yrs/ ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N ☐E ☐C ☐Y ☐N
CCS-Provider-Application-2.docx