Facility Personnel Roster Instructions
This form contains 43 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant/Facility Name | ||
| Applicant or Facility Name | Text |
Please provide the full name of the applicant or the facility.
|
| Date | ||
| Date | Date |
Please enter the date this form is being completed.
|
| Eighth Person Details | ||
| Eighth Person's Name | Text |
Enter the full name of the eighth person, printing the last name first. Fill only if 'Eighth Person's Age' is 13 or older.
Depends on:
Eighth Person's Age
|
| Eighth Person's Age | Text |
Enter the age of the eighth person.
|
| Eighth Person's Role | Text |
Enter the role or function of the eighth person. Fill only if 'Eighth Person's Age' is 13 or older.
Depends on:
Eighth Person's Age
|
| Eighth Person's Social Security Number | Text |
Enter the Social Security Number of the eighth person. Fill only if 'Eighth Person's Age' is 13 or older.
Depends on:
Eighth Person's Age
|
| Facility Address | ||
| Street Address | Text |
Please provide the street number and street name for the facility's address.
|
| City | Text |
Please provide the city for the facility's address.
|
| Zip Code | Text |
Please provide the zip code for the facility's address.
|
| Fifth Person Details | ||
| Fifth Person Name | Text |
Enter the full name of the fifth person, last name first, as it should appear on official documents. Fill only if 'Fifth Person Age' is 13 or older.
Depends on:
Fifth Person Age
|
| Fifth Person Age | Text |
Enter the age of the fifth person in years.
|
| Fifth Person Role | Text |
Enter the role or function of the fifth person within the facility. Fill only if 'Fifth Person Age' is 13 or older.
Depends on:
Fifth Person Age
|
| Fifth Person SSN | Text |
Enter the Social Security Number of the fifth person. Fill only if 'Fifth Person Age' is 13 or older.
Depends on:
Fifth Person Age
|
| First Person Details | ||
| Full Name | Text |
Enter the full name of the first person, printed with the last name first. Fill only if 'Age' is 13 or older.
Depends on:
Age
|
| Age | Text |
Enter the age of the first person.
|
| Role | Text |
Enter the role or function of the first person. Fill only if 'Age' is 13 or older.
Depends on:
Age
|
| Social Security Number | Text |
Enter the Social Security Number of the first person. Fill only if 'Age' is 13 or older.
Depends on:
Age
|
| Fourth Person Details | ||
| Fourth Person Name | Text |
Enter the full name of the fourth person, printing the last name first. Fill only if 'Fourth Person Age' is 13 or older.
Depends on:
Fourth Person Age
|
| Fourth Person Age | Text |
Enter the age of the fourth person.
|
| Fourth Person Role | Text |
Enter the role or function of the fourth person. Fill only if 'Fourth Person Age' is 13 or older.
Depends on:
Fourth Person Age
|
| Fourth Person Social Security Number | Text |
Enter the Social Security Number of the fourth person. Fill only if 'Fourth Person Age' is 13 or older.
Depends on:
Fourth Person Age
|
| Licensing Representative | ||
| Licensing Representative Printed Name | Text |
Please provide the printed name of the licensing representative.
|
| Ninth Person Details | ||
| Ninth Person's Name | Text |
Enter the ninth person's full name, with the last name entered first. Fill only if 'Ninth Person's Age' is 13 or older.
Depends on:
Ninth Person's Age
|
| Ninth Person's Age | Text |
Enter the ninth person's current age.
|
| Ninth Person's Role | Text |
Enter the role of the ninth person as it relates to the facility, choosing from the provided list of roles. Fill only if 'Ninth Person's Age' is 13 or older.
Depends on:
Ninth Person's Age
|
| Ninth Person's Social Security Number | Text |
Enter the ninth person's Social Security Number. Fill only if 'Ninth Person's Age' is 13 or older.
Depends on:
Ninth Person's Age
|
| Provider ID | ||
| Provider ID | Text |
Enter the provider identification number.
|
| Second Person Details | ||
| Second Person Name | Text |
Enter the full name of the second person on the roster, with the last name printed first. Fill only if 'Second Person Age' is 13 or older.
Depends on:
Second Person Age
|
| Second Person Age | Text |
Enter the age of the second person on the roster.
|
| Second Person Role | Text |
Enter the role or function of the second person on the roster. Fill only if 'Second Person Age' is 13 or older.
Depends on:
Second Person Age
|
| Second Person Social Security Number | Text |
Enter the Social Security Number of the second person on the roster. Fill only if 'Second Person Age' is 13 or older.
Depends on:
Second Person Age
|
| Seventh Person Details | ||
| Seventh Person's Name | Text |
Provide the full name of the seventh person, with the last name printed first. Fill only if 'Seventh Person's Age' is 13 or older.
Depends on:
Seventh Person's Age
|
| Seventh Person's Age | Text |
Enter the age of the seventh person.
|
| Seventh Person's Role | Text |
State the role or function of the seventh person. Fill only if 'Seventh Person's Age' is 13 or older.
Depends on:
Seventh Person's Age
|
| Seventh Person's Social Security Number | Text |
Enter the Social Security Number of the seventh person. Fill only if 'Seventh Person's Age' is 13 or older.
Depends on:
Seventh Person's Age
|
| Sixth Person Details | ||
| Sixth Person Name | Text |
Enter the full name of the sixth person, with the last name printed first. Fill only if 'Sixth Person Age' is 13 or older.
Depends on:
Sixth Person Age
|
| Sixth Person Age | Text |
Enter the age of the sixth person.
|
| Sixth Person Role | Text |
Enter the role or function of the sixth person. Fill only if 'Sixth Person Age' is 13 or older.
Depends on:
Sixth Person Age
|
| Sixth Person Social Security Number | Text |
Enter the Social Security Number of the sixth person. Fill only if 'Sixth Person Age' is 13 or older.
Depends on:
Sixth Person Age
|
| Third Person Details | ||
| Third Person Name | Text |
Please enter the full name of the person, with the last name printed first. Fill only if 'Third Person Age' is 13 or older.
Depends on:
Third Person Age
|
| Third Person Age | Number |
Please enter the current age of the person.
|
| Third Person Role | Text |
Please enter the role or function of this person. Fill only if 'Third Person Age' is 13 or older.
Depends on:
Third Person Age
|
| Third Person Social Security Number | Text |
Please enter the Social Security Number of this person. Fill only if 'Third Person Age' is 13 or older.
Depends on:
Third Person Age
|