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Lity Address: Per ARM 37.95.160(2), a current staff list must be maintained for all staff and kept on file at the facility. The department may request this list at any time. This form should be updated whenever there are staff changes. Please Note: If someone is not listed below, they will be taken off of the approved caregiver list. Staff Name 2 3 4 5 6 7 8 9 10 Date of Birth Mailing Address 1 Staff Phone Number City, State Zip PS# or SS# Role Type Date of Hire Termination Date.
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