MARYLANDSTATEDEPARTMENTOF EDUCATION–OfficeofChildCare

CHILDCAREFACILITYPERSONNELLIST/STAFFCHANGEFORM

WithApplications submitted forChild CareCenterLicenses/LetterofCompliances(OCC1200), andRequestsforContinuingLicenses/LetterofCompliances(OCC672), completeandsubmita list of all facility personnel,whetherpaidorunpaid,includingvolunteers whoworkatthefacilityonaroutinebasis,totheOfficeofChildCare(OCC), or as requested by the Office in accordance with COMAR 13A.16 - 18.03.05A.. Click in space to bring up grey text box.

For staff changes, complete with dates and submit totheOfficeofChildCare,within5workingdays of adding or deleting an employee or staff member. Include updated OCC 1206 Staffing Pattern. If new employee is paid, ensure that the individual applied for a Criminal Background Check (CBC) on or before the actual date of employment. As applicable, within 15working days of adding a new staff member, submitOCC Form 1205Individual Personnel Informationwith all required documentation to support the requested position. Click on the ☐ .

NameofFacility: Address: Telephone#:

Email Address:

Facility Personnel

√ Box When Reporting Changes / ☐ ADD / ☐ DEL / ☐ ADD / ☐ DEL / ☐ ADD / ☐ DEL / ☐ ADD / ☐ DEL / ☐ ADD / ☐ DEL
Name of Staff Member
Requested Position Title *
If New Position √ ☐
Date Hired/ # Hours Per Week
Date Applied for CBCs**
Date OCC 1260 Releaseof Information Signed
Date of OCC 1204 Medical
Date of Staff Orientation
Date-Emergency Preparedness
Date-Medication Admin
Date - ADA
Date – Supporting Breastfeeding
Date First Aid Expires
Date CPR Expires
Date – Developmental Screening
Date No Longer Employed
Date of Dir’s Reg. Training
Date of Aide Orientation
For OCC Use Only
Date FBI Received by OCC
Date State Received by OCC
Date Release Reviewed
Date Position Approved

*PositionTitles:Operator,Director, Infant-Toddler, Pre-School or, School-age, Teacher,AssistantTeacher,Aide,FoodServiceWorker,ClericalWorker,Driver,Custodian,Substituteand/or

Volunteer, or Other (those who have frequent contact with children in care).

** On or before the first day of actual employment, an employee must apply for a Criminal Background Check.

Name/Signature of Operator or Director: ______Date: ______

OCC 1203 – Fill-in Version - Revised 3/16 – All previous editions are obsolete Page 1 of 2

ADDITIONALSTAFFMEMBERCHANGEINFORMATION– FACILITY NAME:

Completethissectionifchangeinformationisbeingreported.(i.e.,newstaff,deletinganexistingstaff,staffpositionchanges).Page1mustbesubmittedwithpage2.

NameofStaffMember / TypeofChange / TransferringfromanotherfacilityinMaryland?
AddDate / DeleteDate / Otherchange
(pleaseexplain,i.e.hours,position,ageofgroup) / No / Yes / NameandCountyofpreviousfacility / Dateleft

PLEASE NOTE: Notificationof NewStaff– An operatorshall:

(1)Within5 workingdaysofaddinganew employeeorstaffmember,providetotheOffice:

(a)Writtennotificationoftheindividual’sadditiontothecenterstaff;

(b)Informationabouttheindividual’swork assignment;and

(c)Asignedandnotarizedpermissiontoexaminerecordsofabuseandneglectof childrenandadultsforinformationaboutthe individual;and

(2)Within15 workingdays of addingthenewemployeeorstaffmember,providetotheoffice:

(a)Ifapplicable,documentationthattheindividualmeetstherequirementsofthischapterforthe assignment,unless documentation alreadyisonfileintheoffice,and

(b)Iftheindividualispaidbythecenteroperator,proofof compliancewiththelaws and regulationspertainingto criminal backgroundchecks.

SignatureofOperatororDirector______Date ______

OCC1203–Revised3/16 – All previous editions are obsoletePage2of 2