TCP Employee Clearance Submission Sheet:FY 24/25 DHS Contracts

TCP Employee Clearance Submission Sheet:

FY 24/25 DHS Contracts

Please utilize this form to submit the required clearances for each employee's clearance level as included on your program's Staffing List (905) and TCP Staffing/Clearance Identification Sheet.

Note: An updated 905 and TCP Staffing/Clearance Identification Sheet must be submitted to reflect all staff changes.

Provider/Contract Information

Name of Provider*

Please include the name of your organization.

Program Name*

Please include your program's full name as stated in your contract.

Contract Number*

Please include your correct, FY 24 contract number.

Provider Point of Contact(s)*

Please submit the email(s) of the point-of-contact(s) who will update clearances on a need-be basis.

Employee Information

Name of Staff Member*

Job Title*

Employee Status*

Active - Employed with agency and listed on Staffing List (905) and TCP Staffing/Clearance Identification Sheet

Inactive - No longer employed with agency and no longer listed on 905 and TCP Staffing/Clearance Identification Sheet

Note: Please submit a new Staffing List 905 and TCP Staffing/Clearance Identification Sheet whenever there are any staff changes.

Select

Is this employee a new hire?*

Select

Has this new hire been approved by TCP?*

Select

Start Date of Employment*

Please include the start of employment for the staff member.

Please indicate the employee's Clearance Level as indicated on your submitted TCP Staffing/Clearance Indentification Sheet*

Please visit https://community-partnership.org/wp-content/uploads/2024/03/TCP-Provider-Employee-Background-Clearance-Policy-4.pdf to learn more about each clearance level.

Select

Date of FBI Background Check*

Please submit the date that the employee's FBI background check was administered.

Due Date for FBI Check Renewal*

Please submit the date that the FBI background check will be renewed.

Note: FBI background checks are to be conducted every 2 years from the time of expiration for Safety Sensitive and Protection Sensitive Positions and are required every 4 years for Security Sensitive Positions.

Date of MPD Background Check*

Please submit the date that the employee's MPD background check was administered.

Due Date for MPD Check Renewal*

Please submit the date that the MPD background check will be renewed.

Note: MPD background checks are to be conducted every 2 years from the time of expiration for Safety Sensitive and Protection Sensitive Positions and are required every 4 years for Security Sensitive Positions.

Date of Child and Family Services (CFSA) Clearance Check

Please submit the date that the employee's CFSA background check was administered.

This is a requirement for all providers who work with youth or family programs.

Due Date for CFSA Check Renewal

Please submit the date that the CFSA background check will be renewed.

Note: CFSA background checks are to be submitted every 2 years from the date in which the last clearance was checked/pulled.

Date of National Sex Offender Registry (NSO) Check*

Please submit the date that the employee's NSO background check was administered.

Due Date for NSO Check Renewal*

Please submit the date that the NSO Check will be renewed.

Note: NSO background checks are to be submitted every 2 years. Therefore, the date of renewal should be two years after the last NSO background check was conducted.

Date of Traffic Record Check

A Traffic Record Check is only applicable if the employee drives as part as their routine work duties.

Due Date of Traffic Record Check Renewal

Please submit the date that the Traffic Record Check will be renewed. *Note: This clearance is required every 2 years if the employee drives as part of their routine duties.

Has the staff member had a random drug/alcohol test completed within the past year?*

Please note that Drug and Alcohol Tests are required at the time of hire, for reasonable suspicion, post-accident or incident, return to duty and randomly. TCP now requires its providers to complete random drug and alcohol testing annually.

Select

Please indicate the date that the last drug and alcohol test was completed for this employee.*

Date of TB Test*

Please submit the date that the TB Test was administered.

Due Date for TB Test Renewal*

Please submit the date that the TB Test will be renewed. This date should be two (2) years after the last test was conducted unless a chest x-ray was conducted. Please note that TB tests conducted in the form of a chest x-ray are good for 5 years.

UPLOAD CLEARANCE DOCUMENTS HERE:*

Please submit all clearances required for the employee's clearance level in the below order:

Safety Sensitive:

FBI Background Check (required every 2 years)
MPD Background Check (required every 2 years)
CFSA Clearance (required every 2 years only for employees that work for youth or family programs)
National Sex Offender Registry (required every 2 years)
Traffic Record Check (required every 2 years if the employee drives as part of their routine duties)
Random Drug/Alcohol Screening (required annually)

Protection Sensitive:

FBI Background Clearance (required every 2 years)
MPD Background Clearance (required every 2 years)
Traffic Record Check (required every 2 years if the employee drives as part of their routine duties)
Random Drug/Alcohol Screening (required annually)
TB test (required every 2 years) *Please note that if an employee's TB screening comes back positive, a physical is required.

Security Sensitive:

FBI Background Clearance (required every 4 years)
MPD Background Clearance (required every 4 years)
Traffic Record Check (required every 2 years if the employee drives as part of their routine duties)

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