Form Hcs 501 - Personnel Record
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1CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
FOR HOME CARE ORGANIZATION (HCO) USE ONLY
PERSONNEL RECORD
HCO NUMBER
(Form to be kept current at all times)
HCO ADDRESS
DATE OF EMPLOYMENT
DATE OF SEPARATION
PERSONAL
NAME (LAST
FIRST
MIDDLE)
AREA CODE/TELEPHONE
(
)
ADDRESS
DATE OF BIRTH
SOCIAL SECURITY NUMBER: (VOLUNTARY FOR ID ONLY)
DATE OF TB TEST UPON HIRE
RESULTS OF LAST TB TEST
ADDITIONAL TB TEST DATES (PLEASE INCLUDE TEST RESULTS)
PLEASE LIST ANY ALTERNATE NAMES USED (FOR EXAMPLE- MAIDEN NAME)
CDL NUMBER:__________________________________
DO YOU POSSESS A VALID CALIFORNIA DRIVER'S LICENSE?
YES
NO
POSITION INFORMATION
EMPLOYMENT
(List most recent experience first. If additional space is needed, please attach a separate page.)
AREA CODE/
OB TITLE AND
REASON FOR
NAME AND ADDRESS OF EMPLOYER
LEAVING
TELEPHONE
TYPE OF WORK
(
)
(
)
(
)
(
)
(
)
Notes:
I hereby certify under penalty of perjury that I am 18 years of age or older and that the above statements are true and correct.
I give my permission for any necessary verification.
EMPLOYEE SIGNATURE
DATE
HCS 501 (6/17)
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