Attach C_ DSS Form 1580.pdf
PDF 712 KB Posted
- Attached to
- APS - ETPS - HOMEMAKER - CNAS -PCAS
- Solicitation number
- 5400029952
- Issued by
- Richland County, South Carolina
About this file
This is a certification form issued by the South Carolina Department of Social Services (SCDSS) Adult Protective Services division for verifying the experience of contractor staff providing personal care, certified nursing assistant, or sitter services. The DSS Form 1580 is completed by contractors to certify that their employees have the requisite experience in providing or supervising personal care and certified nursing assistant services. The form requires documentation of the employee's years of experience, which may be accrued through the current licensed provider or other licensed in-home care providers, supported by work records, applications, resumes, or other evidence of employment history.
The form must be signed by the contractor's manager or director and the employee, then submitted to SCDSS Adult Protective Services at the Columbia office address provided. For director-level positions, an alternative administrator must sign to avoid conflicts of interest. Upon completion and approval by an Adult Advocacy Director or designee at the state office, SCDSS returns a signed copy to the contractor's business address. The completed and signed form must be retained in the employee's file at the contractor's facility and made available during SCDSS monitoring visits to maintain compliance with state requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| Solicitation.docx | DOCX document | |
| Attach B_DSS Form 30141.pdf | ||
| Attach A_ DSS Form 2433.pdf | ||
| Attach D_DSS Form 3797.pdf |
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Text version
DSS Form 1580 (3/23/26)
Adult Protective Services
CERTIFICATION OF EXPERIENCE FOR CONTRACTOR STAFF
To be completed by the Personal Care/Certified Nursing Assistant (Sitter) Contractor
Name of Employee: Date:
Contractor’s Business Name:
Contractor’s Mailing Address:
Employee’s Position (Director, Personal Care Assistant, etc.):
I certify that the employee named above has years experience providing personal care/certified nursing assistant services or supervising or managing personal care/certified nursing assistant services.
Note: If this form is verifying experience for the Director, he/she cannot sign as the Manager or Director. Another administrator will need to sign.
Manager or Director Signature Date
Employee Signature Date
Return signed and completed form to: SC Department of Social Services Adult Protective Services P.O. Box 1520 Columbia, SC 29502-1520
To be completed by the SCDSS APS State Office
Adult Advocacy Director or Designee Signature Date
SCDSS will return a copy of the signed and completed form to the Contractor’s Business Address listed above.
This form must be completed with all required signatures and kept in the employee’s file on-site and must be made available upon request during SCDSS monitoring visits.
DSS Form 1580 (3/23/26)
Instructions
1. Enter the name of the employee for whom you are certifying experience in the “Name of
Employee” field.
2. Enter the date that you are completing the form in the “Date” field.
3. Enter the name of the Personal Care/Certified Nursing Assistant (Sitter) Service in the
“Contractor’s Business Name” field.
4. Enter the address of the Personal Care/Certified Nursing Assistant (Sitter) Service in the
“Contractor’s Business Address” field to include the street or post office box address, city, state, and zip code.
5. Enter the employee’s title with the Personal Care/Certified Nursing Assistant (Sitter) Service in the “Employee’s Position” field.
6. Enter the years of experience working for a licensed Personal Care/Certified Nursing Assistant (Sitter) Service in the blank in the statement on the middle of the page. The number of years entered may be for your company and/or another Licensed In-Home Care Provider, but you should be able to provide evidence of the experience through work records, an application, a resume, or other documentation.
7. Have the manager or director of the Personal Care/Certified Nursing Assistant (Sitter) Service sign and date the form. If this form is verifying experience for the director, he/she cannot sign as the Manager or Director. Another administrator will need to sign on this line.
8. Have the employee for whom you are certifying experience sign and date the form.
9. Return the signed and completed form to: SC Department of Social Services
Adult Protective Services P.O. Box 1520 Columbia, SC 29502-1520
| Contractors Business Name: |
| Date: |
| 1: |
| 2: |
| undefined: |
| assistant services or supervising or managing personal carecertified nursing assistant services: |
| Date_2: |
| Date_3: |
| Date_4: |
File details come from the government source that posted it. Updated .