TCP Employee Clearance Submission Sheet:FY 23 DHS Contracts

TCP Employee Clearance Submission Sheet:

FY 23 DHS Contracts

Please utilize this form to submit the required clearances for each employee included on your program's Staffing List (905).

Staff Member and Provider Information

Name of Staff Member*

Job Position*

Employee Status*

Active - Employed with agency and listed on Staffing List (905)

Inactive - No longer employed with agency and no longer listed on 905

Note: Please submit a new Staffing List 905 whenever there are any staff changes.

Select

Start Date of Employment*

Please include the start of employment for the staff member.

Name of Provider*

Program Name*

Contract Number*

Provider Point-of-Contacts*

Please submit emails of point-of-contacts who will update clearances on a need-be basis.

Clearances

Please fill out each field and submit clearances in the file upload section.

Has Staff Member Submitted a Government-Issued Photo ID?*

Please note that expired IDs will not be accepted.

Select

Has Staff Member Received Tuberculosis (TB) Test?*

Please note that TB Tests are to be conducted on an annual basis. Therefore, the expiration date of this clearance will be one (1) year after the date that the test was conducted.

Select

Date of TB Test*

Please submit the date that the TB Test was administered.

TB Test Renewal*

Please submit the date that the TB Test will be renewed. This date should be one (1) year after the last test was conducted.

Has Staff Member Received Negative Drug Test?*

Please note that Drug Tests are to be conducted on an annual basis. Therefore, the expiration date of this clearance will be one (1) year after the date that the test was conducted.

Select

Date of Negative Drug Test*

Please submit the date that the Drug Test was administered.

Due Date for Drug Test Renewal*

Please submit the date that the Drug Test will be renewed. This date should be one (1) year after the last test was conducted.

Date of DC Metro Police (DCMP) Background Check*

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

Due Date for DCMP Background Check Renewal*

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

Note: DCMP background checks are to be conducted on an annual basis. Therefore, the date of renewal should be one (1) year after the last background check was conducted.

Date of Federal Bureau of Investigation (FBI) Background Check*

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

Due Date for FBI Background Check Renewal*

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

Note: FBI background checks are to be conducted on an annual basis. Therefore, the date of renewal should be one (1) year after the last background check was conducted.

Date of Child and Family Services (CFSA) Background 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.

Due Date for CFSA Background Check Renewal*

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

Note: CFSA background checks are to be submitted annually. Therefore, the date of renewal should be one (1) year after the last CFSA background check was conducted.

Date of National Sex Offender Registry (NSO) Background 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 background check will be renewed.

Note: NSO background checks are to be submitted annually. Therefore, the date of renewal should be one (1) year after the last NSO background check was conducted.

COVID Vaccination Proof Submitted*

Please submit COVID vaccination dates. If the employee is exempted or does not have the COVID vaccination, please select "N/A".

Note: Johnson & Johnson vaccine only requires one (1) initial dose.

Select

COVID Vaccine Type*

Please select which vaccine the employee has received.

Note: Johnson & Johnson vaccine only requires one (1) initial dose.

Moderna

Pfizer

Johnson & Johnson

N/A

Date of COVID Vaccination (First)

Date of COVID Vaccination (Second)

COVID Booster Vaccine Received

Select

Date of COVID Booster

File Upload*

Please submit all clearances in a zip folder with the employee's first and last name, in order:

1) Government-Issued Photo ID

2) Tuberculosis (TB) Test

3) Drug Test

4) DC Metro Police (DCMP) Background Check

5) Federal Bureau of Investigation (FBI) Background Check

6) Child and Family Services (CFSA) Background Check

7) National Sex Offender (NSO) Background Check

8) COVID Vaccination Proof

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