| THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR Monitoring Team staff to collect information and supporting documents related to the overall functioning and oversight of the care provider program as part of the pre-monitoring process for biennial site visits. Public reporting burden for this collection of information is estimated to average 13 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov. |
| Personnel Name |
Job Title |
Hire Date |
Employment End Date, if applicable |
FBI fingerprint Clearance/Passed Date |
Child Abuse and Neglect (CA/N) Check Clearance/Passed Date |
Resident of Another State
for the past 5 Years (Yes or no) |
If Resided in other states over the past five years - date of clearance CA/N check |
Background Check Investigation updates |
Explanation for any issues |