Section / Human Resources / Policy number / 3-O
Topic / Personnel Records / Last Review Date / 06/23/16
CARF Standards / 1.H.7.c.(2); 1.I.10 / Date Revision Date / 02/08/16
Purpose / To that the personnel records are clear, correct, complete, current and compliant with agency policies and regulatory requirements
  1. Personnel records have a consistent chart order, including maintaining entries in chronological order, to enable others to locate specific documents
  2. Each staff employed or contracted with the agency has a separate record. Re-hire documentation is maintained in the same chart as the original hire information.
  3. Documents in the personnel record have original signatures.
  4. Personnel records and Staff Database contain demographic information, including the following:
  5. Staff’s legal name
  6. Date of birth
  7. Social Security Number (password protected in Staff Database)
  8. Current street address, phone number, email address
  9. Emergency contact information, including name & phone number
  10. Personnel records contain documents and information related to employment, including the following:
  11. Resumé, which serves as the application for employment
  12. Employment references for all work locations in the past 2 years (minimum of 2), which includes verification of competencies required for the position
  13. Date of hire or contract start date, for contracted staff (also contained in Staff Database)
  14. Signed job descriptions or contracts, containing start dates for each position (job title, start/end dates also contained in Staff Database)
  15. Current pay rate and history of pay changes (password protected in Staff Database)
  16. W4 (employee) or W9 (contractor)
  17. I-9 & required attachments (e.g., copies of driver’s license, social security card, birth certificate, and/or work visa)
  18. Annual performance evaluations
  19. Corrective action, if applicable
  20. Leave of Absence Request, if applicable (LOA start/end dates also contained in Staff Database)
  21. If applicable, Student intern/volunteer written agreement & assessment of performance
  22. Personnel records contain clearance records required by regulatory agencies, including the following:
  23. Level 2 State and Federal criminal background checks(printed from a state-secure portal), updated every 5 years (clearance & expiration date contained in Staff Database)
  24. Local Law Enforcement check
  25. Affidavit of Good Moral Character (notarized)
  26. Results of search by Office of the Inspector General, Health & Human Services verification showing no exclusion records (e.g., fraud, licensing)
  27. Personnel records contain credentialing documentation, including the following:
  28. Description of prior work experience, contained in the resume or vita
  29. Copy of degree/diploma or transcript indicating degree conferred, if required for position (degree type also contained in the Staff Database)
  30. Unexpired copy of professional license, registered internship, or certification, if required for the position (license/certification type, number, original issue date, and expiration date also contained in the Staff Database)
  31. Primary source verification of license or certification
  32. National Provider Identifier (also contained in Staff Database)
  33. CAQH registration number, if applicable(also contained in Staff Database)
  34. Personnel records contain documentation of trainings, including the following:
  35. Orientation training
  36. Initial and annual CARF-required training
  37. Trainings required in Corrective Action plans
  38. Other training required for the position
  39. Other voluntary trainings attended
  40. Personnel records are assembled within 2 weeks after the staff’s hire date. Post-hire records are delivered to the Human Resources office within 2 weeks after receipt and are filed in the personnel record within 2 weeks after receipt by the Human Resources office.

69 / 1.H.7.c.(2) / There is immediate access to relevant emergency information on the personnel / Promoting Health & Safety, Personnel Records, Disaster plan
77 / 1.I.10.a / Records for personnel contain the employment application or resume / Personnel records
77 / 1.I.10.b.(1) / Records for personnel contain verification of credentials, including certification, licensure, or registration, when applicable / Personnel records
77 / 1.I.10.b.(2) / Records for personnel contain verification of competencies / Personnel records
77 / 1.I.10.c / Records for personnel contain evidence of orientation / Personnel records
77 / 1.I.10.d / Records for personnel contain criminal background checks, when applicable / Personnel records
77 / 1.I.10.e / Records for personnel contain other information required by law / Personnel records

Human Resources – Personnel Records