Dhcs 5050 2013 form-2025

1. Click ‘Get Form’ to open the dhcs 5050 2013 form in the editor.
2. Begin by entering the Facility Name and Provider Number at the top of the form. Ensure that you designate volunteers by placing a 'V' next to their names.
3. In the Counselor Information section, fill out each staff member's details, including their title, scheduled hours per week, and whether they are certified, registered, or licensed. Remember that at least 30% of counseling staff must be licensed or certified.
4. For each employee listed, provide additional information such as Date Hired, Last TB Test Date, and First Aid/CPR training dates. This ensures compliance with facility requirements.
5. Complete the Effective and Expiration Dates for Licensure, Certification, or Registration for each staff member. Include certification numbers and organizations as required.

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