License/Registration/Approval No.:

South Carolina Department of Social Services

Child Care Licensing and Regulatory Services

SECTION 3: CURRENT CHILD CARE FACILITY STAFF/CAREGIVER CHECKLIST

Name of Facility: County: Date:

DSS Form 2964 (MAR 10) Edition of MAR 94 is obsolete.

To be completed by the child care facility operator – include emergency personnel For DSS Child Care Licensing Only

To BeCollected/Verified byLicensingSpecialist

To Be Maintained in Employee File

Name Position Date of Birth Social SecurityNumber

Prim

ary

Ag

e G

rou

p A

ssig

ne

d

Ye

ars

of

Exp

erie

nce

s

Tra

inin

g R

eco

rd

BB

P T

rain

ing

All

Po

licie

s

Fin

ge

rprin

t R

esu

lts

SL

ED

Re

su

lts

TB

Te

st

DS

S F

orm

29

26

DS

S F

orm

29

25

DS

S F

orm

29

24

DS

S F

orm

29

01

First A

id

CP

R I

nfa

nt/C

hild

Ed

. L

eve

l V

erifie

d*

Em

plo

ym

en

t E

nd

Da

te

Em

plo

ym

en

t S

tart

Da

te

Days/Hours on

Duty

Example:M-F/8-5

Total Staff: (Page of ) *Verify educational level by listing the diploma or degree Use additional pages if necessary