5-Tier 1 CNACI Child Care Checklist.pdf
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- 246-25-Q-0067
About this file
This document is a Background Investigation form from the Oklahoma City Area Indian Health Service, designed to capture an employee's residential and work history across all U.S. states for the past 7 years. The form provides a comprehensive checklist of 50 states, allowing the employee to indicate where they have lived and/or worked during that time period. The form includes space for the employee's signature and date, with an option to check if they have not lived or worked in any of the listed states during the specified timeframe.
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Text version
OKLAHOMA CITY AREA INDIAN HEALTH SERVICE
BACKGROUND INVESTIGATION
For the past 7 years, please check ALL states you have lived and/or worked in.
Alabama Indiana Montana Ohio
Alaska Iowa Nevada Rhode Island
Arkansas Kansas New Hampshire South Dakota
California Kentucky New Jersey Tennessee
Colorado Michigan New Mexico Texas
Delaware Minnesota New York Utah
Idaho Mississippi North Carolina West Virginia
Illinois Missouri North Dakota Wyoming
Employee Signature: ____________________________ Date: ___________
Check if not lived and/or worked in above states in the past 7 years:
Untitled
| Alaska: Off |
| Alabama: Off |
| Arkansas: Off |
| California: Off |
| Colorado: Off |
| Delaware: Off |
| Idaho: Off |
| Illinois: Off |
| Indiana: Off |
| Iowa: Off |
| Kansas: Off |
| Kentucky: Off |
| Michigan: Off |
| Minnesota: Off |
| Mississippi: Off |
| Missouri: Off |
| Montana: Off |
| Nevada: Off |
| New Hampshire: Off |
| New Jersey: Off |
| New Mexico: Off |
| New York: Off |
| North Carolina: Off |
| North Dakota: Off |
| Ohio: Off |
| Rhode Island: Off |
| South Dakota: Off |
| Tennesse: Off |
| Texas: Off |
| Utah: Off |
| West Virginia: Off |
| Wymoning: Off |
| Date2_af_date: |
| Check Box1: Off |
File details come from the government source that posted it. Updated .