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Get IL CFS 508-1 2013-2024

CFS 508-1 Rev. 12/2013 State of Illinois Department of Children and Family Services Date Submitted INFORMATION ON PERSON EMPLOYED IN A CHILD CARE FACILITY I. NOTE ATTACH THIS FORM TO THE CFS 508 AND SUBMIT IT TO YOUR DCFS LICENSING REPRESENTATIVE V. Other Direct Unpaid Experience with Children Such as scout work Sunday School teacher Report of Reference on File At least three character and/or business from persons not related to the employee Name of Reference VI. Relationship Educational Background Circle the one item indicating highest grade completed Elementary Grade High School GED 0 1 2 3 4 5 6 7 8 Years of College Undergraduate Years of Graduate Work Yes College Degree No Graduate Degree Name of School College or University last attended Other Special Training or Professional License Specify Professional License Number Evidence of Educational Achievement on File Explain Physical Examination Last Examination Date Health Clearance Report on File VIII. Employing Facility Facility Provider ID Address Street and Number II. City Zip Code Person Employed Date of Birth Social Security Number - Phone Home Address Employment Date Employed Position for which employed Check appropriate item Executive Superintendent or Director Child Care Supervisor child care institution Child Care Worker child care institution Child Care Staff group home Child Welfare Supervisor child welfare agency Child Welfare/Licensing Worker child welfare agency Registered Nurse Teacher residential facility Housekeeping IV. Licensed Practical Nurse day care center only Early Childhood Teacher day care center School-age Worker day care center School-age Assistant day care center Substitute Cook Clerical Other Previous Employment Last ten years of employment From To Name and address of Employer Type of Work and Title The employer or authorized official of the employing facility has contacted the human resources personnel management or knowledgeable supervisor for each listed previous employer to inquire about the employee s work performance and whether the employee would be eligible for rehire. NOTE ATTACH THIS FORM TO THE CFS 508 AND SUBMIT IT TO YOUR DCFS LICENSING REPRESENTATIVE V. Other Direct Unpaid Experience with Children Such as scout work Sunday School teacher Report of Reference on File At least three character and/or business from persons not related to the employee Name of Reference VI. Relationship Educational Background Circle the one item indicating highest grade completed Elementary Grade High School GED 0 1 2 3 4 5 6 7 8 Years of College Undergraduate Years of Graduate Work Yes College Degree No Graduate Degree Name of School College or University last attended Other Special Training or Professional License Specify Professional License Number Evidence of Educational Achievement on File Explain Physical Examination Last Examination Date Health Clearance Report on File VIII. Certification of Employment person is employed in the position indicated and that to the best of my knowledge is qualified for the position indicated and employment is in accordance with minimum standards prescribed by the Department of Children and Family Services. .

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