Compliance Year: ____________ to ______________

Staff File Checklist Name of Employee ________________________________ Center ________________

Date of Employment _________ Position_______________ Date of Birth _______________

The following items must be present in each staff member’s personnel file

State Required Item Received Date Expires

Application

Staff Medical Report (within 60 days of employment)

TB Test

Emergency Information on Staff/ Health Questionaire

Documentation of Staff Orientation

Criminal Records Qualifying Letter

Mandatory Criminal History Check

Education and Equivalency Form (Attachments: Transcript, High School Diploma, NCECC, NCECAC) Date Sent:___________ (w/in 6 months of employment)

***Refer to section 2 of the state book for education requirements***

Education Equivalency Letter (replaces Education and Equivalency Form above)

Inservice Training Documentation (Date Requirement Met:_________)

ITS SIDS (required for Infant/Toddler Teacher)

BSAC (required for SA Group Leader/Bus Driver)

Playground Safety (required for SA Group Leader/Bus Driver)

Annual Staff Evaluation

Staff Development Plan

Employee Handbook Receipt/Job Description Receipt

First Aid Training

CPR Training

Two Reference Letters

Partners In Learning Required Documentation Received

Statement of Commitment

Statement of Confidentiality

Safe Working Practices Agreement

Social Networking Policy

Account Paperwork (Attachments: New Hire Checklist, W-4, NC4,NC New Hire Reporting Form, I-9, Two forms of ID, Direct Deposit Info)

Date Sent: ________ Initals: _______

REV 8/92 Application for Employment (Fully complete both sides of form)

!

Please Print

Date of Application

Position Applied For:

Date of Birth:

/ N. C. Driver's License Number (month) (day) (year)

Have you ever been convicted of breaking a law other than a minor traffic violation? (The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying.)

YES NO If yes, give the date and explain fully on an additional piece of paper if more space is needed

!

!

Circle the

completed:

highest grade

Education 1 2 3 4 5 6 7 89 10

I I 12 GED College 1 2 3 4

Social Security Number Last Name First Name Middle Name

Address (street number and name) City County

State Zip Code Phone (home or where you can be reached) Business Phone

Schools Name and Dates Coursed of Study

Degree/DiplomaHigh School to

Colleg

e or

Univer

sity

toto

to

toto

Graduat

e or

Professi

to

to

Educati

o n a l ,

to

to

Child care training you have completed in the last three years (such as first aid, CPR, CDA, etc.) -

!

References List the names, addresses and phone numbers of two people we may contact as

references:

!

!

Educati

o n a l ,

Vocatio

n a l

toto

Work History (List child care/early childhood experience

first.)

I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures are given to meet position qualifications.

Current or Last Employer Address

Job Title Supervisor's Name No. Supervised by you

Date Employed (mo/yr) Starting Salary $ Per

Ending Salary $ Per

Reason for leaving May we contact employer? yes no

Date Separated (mo/yr) Duties:

Full Time Years Months

Part Time Years Months

If part time, number of hours per week

Current or Last Employer Address

Job Title Supervisor's Name No. Supervised by you

Date Employed (mo/yr) Starting Salary $ Per

Ending Salary $ Per

Reason for leaving May we contact employer? yes no

Date Separated (mo/yr) Duties:

Full Time Years Months

Part Time Years Months

If part time, number of hours per week

Current or Last Employer Address

Job Title Supervisor's Name No. Supervised by you

Date Employed (mo/yr) Starting Salary $ Per

Ending Salary $ Per

Reason for leaving May we contact employer? yes no

Date Separated (mo/yr) Duties:

Full Time Years Months

Part Time Years Months

If part time, number of hours per week

Signature of Applicant __________________________________Date _____________________

Staff Medical Report (To be completed by all staff and placed on file upon initial employment)

TO BE COMPLETED BY THE PHYSICIAN Some lifting of young children and some picking up and moving of furniture and equipment may be required. Since we are vitally involved with the wholesome emotional growth of the child, we require good mental and physical health of our employees.

• Does this applicant have any physical condition which would limit their work with children? If yes, please describe: ________________________________________________________________ ________________________________________________________________________________________________________________________________

• Is this applicant currently under treatment which would preclude their work with children? If yes, please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

• Is this applicant currently under treatment for any specific condition(s)? If yes, please describe: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

• Is this applicant currently taking any medication that would affect his/her work with children? If yes, please describe: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

• In your opinion, is this applicant emotionally and physically capable to care for children on a daily basis? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

_____________________________ ____________________________ Date of Examination Phone Number _____________________________ ____________________________ Signature of Physician ___________________________ ____________________________ Address

Name ________________________________________________________________________ Last First Middle/Maiden Home Address __________________________________________________________________ ______________________________________________________________________________

Tuberculin (TB) Test All staff members are required to have a negative test result before coming in to contact with children. Volunteers and Substitutes present more than once per week must also

have evidence of a negative test.

Evidence of tuberculin test:

Type of test _________________________________ Date given _____/_____/ ________

Result Negative Positive

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________ Signature of Authorized Professional _____________________________________ _____________________________________ _____________________________________ Address ( ) _______-_______________ Phone Number

Name ______________________________________________________________ Last First Middle/Maiden Home Address _______________________________________________________ ___________________________________________________________________ Telephone Number ( ) _____-_______________

EMERGENCY INFORMATION ON STAFF

Staff Health Questionnaire Important current health information must be completed annually by: All staff (including the director). (2)

All volunteers* and substitutes* prior to their coming into contact with the children.

! 1. I am in excellent mental and physical health and am free of communicable

disease. (If not, please explain): ______________________________________________________________

2. I take the following medications regularly (please explain): ______________________________________________________________

This health statement is accurate to the best of my knowledge. I will advise the director if my health status changes.

___________________________________________ ______/______/_____________ Signature Date *Any substitute or volunteer who is counted in the mandatory staff-child ration must comply with the health standards for the staff.

Name ______________________________________________________________ Last First Middle/Maiden Home Address _______________________________________________________ ___________________________________________________________________ Telephone Number ( ) _____-_______________

Name ____________________________________________________________________ Address____________________________________________________________________ Name of Doctor ____________________________Phone ( ) ________-______________ Hospital Preference _________________________Phone ( ) ________-_______________ Name of Dentist ____________________________Phone ( ) ________-______________ To avoid any adverse drug reaction during an emergency, please list medications you are taking: ___________________________________________________________________________ Allergies: ___________________________________________________________________ Blood Type (if known) ________________________________________________________ List operations/hospitalizations within the past year __________________________________________________________________________ List chronic medical problems requiring a doctor’s care ___________________________________________________________________________

Emergency Contact Persons Name ____________________________________ Relationship _______________________ Contact number ( ) _____-_____________ Contact number ( ) _____-____________ Address ____________________________________________________________________ Name ____________________________________ Relationship _______________________

Documentation of Staff Orientation

Name of Employee: ____________________________ Date of Employment: _________________

Intent of rule: Each staff member hired who has contact with the children, will receive a minimum of 21 clock hours of on-site orientation. Within the first two weeks of employment, new employees must complete 7.5 clock hours of training and orientation in the highlighted topic areas listed below. The remaining 13.5 clock hours or orientation must be completed within the first six weeks of employment. This orientation must include, but not be limited to, the contact areas identified in the chart below.

Topic Training Provider (Signature required)

Hours Date

Licensing Laws, Regulations & Child Care Handbook, Fire Safety, Tornado Safety, and Emergency Procedures

Cindie Irvin: 30 Min

Maintaining a safe/healthy environment, diaper changing procedures, SIDS Jennifer Misenheimer: 30 Min

Classroom Arrangement/Cleaning/Organization Playground Zones and Safety Cindie Irvin: 30 Min

Freezer, Refrigerator, Microwave, Coffee, Trash, Washer, Dryer Dianne Neubacher: 15 Min

Center Observation/Perform Rating ScaleDeborah Howell: 4 Hours

Overview of Enhanced License standards and observations Norma Honeycutt: 45 Min

Curriculum/Lesson Plans, PIL resourcesDeborah Howell: 30 Min

Inclusion (IEP/IFSP), Recognizing symptoms of child abuse and neglect Cindy Webb: 2 Hours

Documentation (daily reports, portfolios, incident reports) Ashlee Hawkins: 30 Min

Parent Handbook, Center Tour & Staff IntroductionShaina Freeze: 1 Hour

Field Trip Procedure (Bus Safety and emergency procedures) Shaina Freeze: 30 Min

SEFEL OrientationKatherine Generaux: 2 Hours

Child Guidance/Voice Tone/RulesAshlee Hawkins: 30 Min

Proper Hand washing ProceduresDebra Jean: 30 Min

Review of individual job-specific duties, responsibilities, and job description Deborah Howell: 1 Hour

Review of personnel policies, overview of state and local government agencies Emilie Scharf: 1 Hour

Videos-Creative Curriculum, Toddler, PIL, CACFP, and Foundations Online Training Deborah Howell: 5 Hours

Center WellnessMary Short: 30 Min

“I have received training in the topics listed above.”

_________________________________________

DCD-0049

NOTICE_ CHILD CARE PROVIDER MANDATORY CRIMINAL HISTORY CHECK_

North Carolina law requires that a criminal history check be conducted on all persons who provide child care in alicensed or registered child care facility, and all persons providing child care in nonlicensed child care homes, Or facilitiesthat receive state or federal funds.

"Criminal history includes county, state, and federal convictions or pending indictments of any of the following crimes:the following Articles of Chapter 14 of the General Statutes: Article 6, Homicide; Article 7A, Rape and Kindred Offenses;Article 8, Assaults; Article 10, Kidnapping and Abduction; Article 13, Malicious Injury or Damage by Use of Explosive orIncendiary Device or Material; Article 26, Offenses Against Public Morality and Decency; Article 27, Prostitution; Article39, Protection of Minors; Article 40, Protection of the Family; and Article 59, Public Intoxication; violation of the NorthCarolina Controlled Substances Act, Article 5 of Chapter 90 of the General Statutes, and alcohol-related offenses such assale to underage persons in violation of G.S. 188-302 or driving while impaired in violation of 0.5, 20-138.1 through G.S.20-138.5; or similar crimes under federal law or under the Jaws of other states. Your fingerprints will be used to check thecriminal history records of the State Bureau of Investigation (881) and the Federal Bureau of Investigation (FBI).

If it is determined, based on your criminal history, that you are unfit to have responsibility for the safety and well-beingof children, you shall have the opportunity to complete, or challenge the accuracy of, the information contained in the SB!or FBI identification records.

If you disagree with the determination of the North Carolina Department of Health and Human Services on yourfitness to provide child care, you may file a civil lawsuit in the district court in the county where you live.

Any child care provider who intentionally falsifies any information required to be furnished to conduct the criminalhistory shall be guilty of a Class 2 misdemeanor.

PRIOR CONVICTION/PENDING INDICTMENT STATEMENT (Please check one

I swear, under penalty of perjury, that I have been convicted of a crime and/or I have pending indictments or pending charges that are not minor traffic violations.

I swear, under penalty of perjury, that I have not been convicted of a crime, nor have any pending indictments or

pending charges, other than a minor traffic violation.

I also swear that I am , am not under a deferred prosecution agreement or on probation for a crime. If I have

been convicted of a crime. have pending indictments or pending charges. am under a deferred prosecution agreement,

have received a Prayer for Judgment, or am on probation for a crime, I understand that my employment is conditional

pending approval from the Division of Child Development. 1 also understand that I may submit to the Division of Child

Development additional information concerning the conviction or charges that could be used by the Division in making

the determination of my qualification for employment. The Division may consider the following in making their decision:

length of time since conviction; nature of the crime; circumstances surrounding the commission of the offense or offenses;

evidence of rehabilitation; number of prior offenses; and my age at the time of occurrence.

_______________________________________________________________________

Signature Printed Name Date The Division of Child Development makes no representations regarding this person's eligibility

Maintain Original Form in Employee Personnel File

______________________________

Signature of Employee Date

DCD Use OnlyNorth Carolina Division of Child Development Education and Equivalency Form for Child Care Providers DCD.0169) (use for all positions except Administrator - See Instruction Pages) Please print or type.

WFID#

Signature _________________________________________ Date ________________________________

Applicant should retain a copy of this form and any attached documentation for his/her records.

DCD.0169 -8/01/09

□ Lead Teacher

□ Teacher□ FCCH Provider□ Group Leader □ HS+BSAC □ Currently Enrolled in BSAC□ Program Coordinator □ 2 sch Child/Youth Dev AND 2 sch School-Age Programming □ School-Age Child Care Credential

□ Lead Teacher + BSAC □ Admin + BSAC

D) Educational Qualification-Check the position(s) for which you are applying to qualified. Then check the option(s) for how you

Documentation of In-service Training

Name of Employee _________________________ Date of Hire ______________________ Record Year Beginning________________ Training Hours Required _________

Hours Brought Forward __________

Training Date Number of Training Hours

Received

Topic Instructor Sponsor

This statement must be signed and dated by the applicant: I attest to the accuracy of the above information.

(Attach documentation of attendance, agendas, etc for each training event or keep record in employees file for reviewed by Division of Child Development State Consultant.)

!

Employee Handbook and Job Description Receipt

I, the undersigned, acknowledge that I have reviewed the online version of the Partners in Learning Child Development Center, Inc. Staff Handbook. I have also reviewed the job description pertinent to my current position. I have been advised that written copies of both of the fore mentioned documents are available to me at any time.

I also acknowledge that: • I understand the policies and employment standards cited in the handbook and job description. • I understand I am accountable to the policies and employment standards cited in the handbook and job description. • I understand that that I will be provided with a copy of all changes to this handbook and/or job description as soon as

they are approved for inclusion.

Furthermore, I acknowledge with my signature below my willingness to abide by the policies and employment standards cited in the handbook and job description.

_________________________________ __________________ Employee Signature Date

Partners In Learning Safe Working Practices Agreement

As a condition of employment, I _______________________________________ do hereby agree to comply with the following Safe Work Practices:

1. I agree to follow established company safety procedures. 2. I agree to report work related accident or injury to my supervisor as soon as it occurs, or no later

than 24 hours. 3. If I need treatment for a work related injury I agree to:

a) Notify my employer of the need for treatment b) Go only to the employer directed physician(s) for necessary treatment. c) At the initial visit carry necessary authorization for treatment forms, return to work

capabilities forms as instructed by my employer. 4. As a continuing effort to promote safety I agree to attend in-service safety programs as requested. 5. I agree to cooperate with any post- accident investigations and participate in the Transitional Return

to Work Program when released by a physician to do so.

I understand failure on my part to follow the above procedures could result in disciplinary action.

I also understand that according to Chapter 97-12 of the General Statutes of the North Carolina Worker’s Compensation Law, my compensation benefits could be reduced for any injury which occurs because of my failure to follow established safety procedures.

First Offence: Verbal Warning Second Offence: Written Warning Third Offence: 3 Day Suspension without pay Fourth Offence: Dismissal

______________________________________ __________________________ Employee Signature Date

______________________________________ __________________________ Witness Date

Partners In Learning Statement of Commitment

As an individual who works with young children, I commit myself to furthering the values of Early Childhood Education as they are reflected in the NAEYC Code of Ethical Conduct.

To the best of my ability, I will:

▪ Ensure that programs for young children are based on current knowledge of child development and early childhood education.

▪ Respect and support families in their task of nurturing children.

▪ Respect colleagues in early childhood education and support them in maintaining the NAEYC Code of Ethical Conduct.

▪ Serve as an advocate for children, their families, and their teachers in community and society.

▪ Maintain high standards of professional conduct.

▪ Recognize how personal values, opinions, and biases can affect professional judgment.

▪ Be open to new ideas and be willing to learn from the suggestions of others.

▪ Continue to learn, grow, and contribute as a professional.

▪ Honor the ideals of principles of the NAEYC Code of Ethical Conduct.

With my signature below, I acknowledge my understanding and willingness to abide by the aforementioned Statement of Commitment.

___________________________________________ ______________________________ Employee Signature Date

Partners In Learning Internet Social Networking and Blogging Policy for Employees

In general, our company views social networking sites (e.g., Facebook, My Space, etc.), personal Web sites, and Weblogs positively and respects the right of employees to use them as a medium of self-expression. If an employee chooses to identify himself or herself as an employee of Partners In Learning of Salisbury, Inc. on such Internet venues, some readers of such Web sites or blogs may view the employee as a representative or spokesperson of the company. In light of this possibility, our company requires, as a condition of employment, that employees observe the following guidelines when referring to the company, its programs or activities, its clients (parents or students), and/or other employees, in a blog or on a Web site.

1. Use of Social Networking sites is prohibited while working and should not interfere with work activities

2. Employees must be respectful in all communications and blogs related to or referencing the company, its clients (parents or students), and/or other employees.

3. Employees must not use obscenities, profanity, or vulgar language.

4. Employees must not use blogs or personal Web sites to disparage the company, clients (parents or students), or other employees of the company.

5. Employees must not use blogs or personal Web sites to harass, bully, or intimidate other employees or clients (parents or students). Behaviors that constitute harassment and bullying include, but are not limited to, comments that are derogatory with respect to race, religion, gender, sexual orientation, color, or disability; sexually suggestive, humiliating, or demeaning comments; and threats to stalk, haze, or physically injure another employee or client (parents or students).

6. Employees must not use blogs or personal Web sites to discuss engaging in conduct that is prohibited by company policies, including, but not limited to, the use of alcohol and drugs while working, sexual harassment, and bullying.

7. Employees must not post pictures or make references to students or other employees on a Web site or networking page without written consent.

8. Social networking activities outside of work may be viewed by Company management, and may be taken into account in assessing the employee’s performance, loyalty, etc.

9. Publication of information on social networking sites must comply with all company policies regarding ethics, privacy, and the protection of confidential and proprietary information.

10. Employees should be transparent—don’t hide behind phony identities.

11. Employees must be respectful of Company, Coworkers, Competitors, and Colleagues, as their online activities, whether during or outside of work, reflect upon the company.

12. Our company does host a social networking site. The use of our copyrighted company name or logo is not allowed without written permission.

Any employee found to be in violation of any portion of this Social Networking and Blogging Policy will be subject to immediate disciplinary action, up to and including termination of employment. Any former employee found to be in violation of any portion of this Social Networking & Blogging Policy will be subject to action taken against them for the removal of the violating occurrence up to and including legal action.

____________________________________________ ___________________ Employee Signature Date

Partners In Learning Statement of Confidentiality

The importance of confidentiality as related to exception children and their programs is clearly emphasized by Public Law 94-142, the North Carolina Creech Bill and Partners In Learning Child Development Center’s policies. Adherence to these and all other rules and regulations regarding the rights of handicapped children is mandatory. This statement is verification that all personnel (including assistants) working with children, programs, and records are to remember that confidentiality is to be an ethical principle to follow at all times. This statement signifies commitment to this belief and these practices.

Examples of confidentiality include, but are not limited to:

1. Withholding personal information about a particular student from your friends and relatives as well as the citizenry at large.

2. Withholding a student’s identification when discussing achievement or behavior with coworkers except in a “need to know” context.

3. Maintaining all confidential information in a secure (locked) environment with controlled access.

If there is a question as to confidentiality and the sharing of information, DO NOT share information until you have cleared it through a Partners In Learning administrator or Inclusion Specialist. Upon signing this document, you will be held accountable for any information within your possession.

___________________________________ __________________________________ _________

Printed Name Signature Date

Staff Development Plan

Part I Employee Information

Part II Professional Goals

Employee Name ____________________________________________ Childcare Experience

(years) ________

Classroom _________________________ Ages of children in classroom

______________________________

Employee Signature ___________________________________ Date ___________

1. What is your continued education plan for the next year or longer? Please list what school and what

degree.

_________________________________________________________________________________

___________________

_________________________________________________________________________________

___________________

If not attending college, how do you plan on continuing your education and developing yourself

professionally?

_________________________________________________________________________________

___________________

_________________________________________________________________________________

___________________

2. How many classes do you plan on taking in the field of Early Childhood Education? (If degree is not

complete, a minimum of one class per semester is required).

_________________________________________________________________________________

___________________

3. What are your long term goals in Child Development? (teaching, directing, owning, early

intervention, etc.)

_________________________________________________________________________________

___________________

_________________________________________________________________________________

_________________________________________________________________________________

______________________________________

4. In what areas do I need to concentrate on improving in the next 6-12 months? How can PIL help you

in these areas?

_________________________________________________________________________________

___________________

_________________________________________________________________________________

___________________