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PERSONNEL INFORMATION FORM SectioChild CThis lorm must be submilled lo DHS lor each employee ai Ihe lime of employmeni and any lime ihere is a change in classificaiion of position.All staff must meet applicable employmeni conditions, staff qualifications and training as required In Mn. Rules parts 9503 0005-9503.0170. Compfefe all applicable blanks to show compliance with the ruleEach employee's personnel file must contain appropriate verification of the information on this form.PrograiName of EmployeeName ol Ceniei Location;Dale of Employment:Job TitleAge groupfs) with which you work:□ Infant □ Toddler □ Preschool □ School Age <br />ALTERNATIVES FOR QUALIFICATION: <br />Refer lo Minnesota Ruies part 9503 0031 0034 lo delermina which alternaMvo is appropriate for the position you hold. <br />Teacher: 1 23466789 <br />Assistant Teacher: 1 23466789 Complete sections I. II and III on the reverse side ol this form to show <br />Child Caro Assistant (Aide): □ vou qualify for the alternative circled. For some ahernsiives. not all <br />Volunteer: D Other: □ <br />Director; □ <br />Total <br />sections are required. <br />S«c <br />DECLARATION <br />The information on this form is true to the best of my knovdedge. Oocumeniaiion of credentials, work ercperience and acaedited child (tevelopment training courset <br />necessary to verify compliance with MN Rules parts 9503 0005 9503 0170 requiremania la on file in ihia employee's file. I understand that this Informatioit may <br />be reviewed by the licensor. <br />Signature of bmployee Signature of Employef <br />Date comptetad Date complelad