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{"sheet":"PCS-102SIL-RevMarch2013","index":0,"n_rows":50,"n_cols":12,"rows_kept":50,"cut":false,"hidden":false,"merged":[[42,0,42,8],[6,4,7,4],[5,9,7,9],[5,0,7,1],[5,10,7,10],[45,0,45,8],[46,0,46,8],[8,2,8,8],[0,0,0,8],[2,0,2,1],[2,3,2,8],[6,5,7,5],[4,0,4,11],[5,11,6,11],[6,3,7,3],[6,8,7,8],[5,2,5,8],[41,0,41,10],[6,6,7,6],[6,7,7,7],[6,2,7,2]]}
[]
["Name of Contractor",null,null,null,null,null,null,null,null,null,"Contract or Procurement Number"]
[]
["Individual Completing Form",null,null,"Date",null,null,null,null,null,null,"Email"]
["List contracting entity and all names(s) of key personnel, staff, subcontractors,  host homes residents/regular visitors, related parties, those with access to Young Adults records and volunteers working under this contract."]
["\nStaff/ Subcontractor/ Volunteer/ Related Party / Direct Providers / Management, Financial and Administrative Services / Key Personnel\n \nEnsure individual names are in Title Format: Last, First\nExample: Smith, John PHD or AAA Counseling",null,null,null,null,null,null,null,null," Direct Provider Primary Service Type \n(Chose from List of Services if applicable)\n\n","Name of SIL Setting Association if applicable. (Indicate \"N/A\" if individual is supporting the entire program)\n","Background Check "]
[null,null,"Volunteer","Subcontractor","Employee","Direct Provider","Related Party","Management, Financial, Administrative Services","Key Personnel"]
[null,null,null,null,null,null,null,null,null,null,null,"Requested \nDate"]
["ID #"," Name of Individuals as Referenced Above","Check All that Apply",null,null,null,null,null,null,"For Direct Provider, Enter Type of Direct Service ","For those associated for SIL Setting, enter SIL Setting Name ","For Employees, Subcontractors & Volunteers"]
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["I certify that as of the Acknowledgment Date this list accurately represents the persons working under this contract and identifies their role(s). Furthermore, I understand that I must submit this report to the DFPS Residential Contract Manager at least annually.  I understand that I must submit a background check through ABCS for each individual in accordance to the SIL Contract.  I also understand that I must submit a background check through ABCS, at a mimimum, initially for each person and every 24 months thereafter."]
[]
["Contracting Entity Signatory",null,null,null,null,null,null,null,null,null,"Acknowledgment Date"]
[]
[]
["Residential Contract Manager Approval",null,null,null,null,null,null,null,null,null,"Approval Date"]
[]
["Approval Exceptions:"]
["The service providers (identified by ID #) listed below have not been approved to work under this contract."]