Attach C_ DSS Form 1580.pdf
PDF 712 KB Posted
- Attached to
- APS - ETPS - HOMEMAKER - CNAS -PCAS
- Solicitation number
- 5400029256
- Issued by
- Richland County, South Carolina
About this file
This is a DSS Form 1580, an experience certification form issued by the South Carolina Department of Social Services (SCDSS) Adult Protective Services division for use with Personal Care Assistants (PCAs), Certified Nursing Assistants (CNAs), and Sitter Service contractors. The form serves as documentation to verify that contractor staff members possess the requisite experience to perform personal care or certified nursing assistant services, or to supervise and manage such services. Contractors must complete the form for each employee, documenting the employee's name, position title, years of relevant experience, contractor business name and mailing address, and the date of certification. The form requires signatures from both the contractor's manager or director (or another administrator if certifying a director's experience) and the employee being certified, with all documentation to be submitted to the SCDSS APS office at the specified Columbia, South Carolina address.
The completed and signed form must be retained in the employee's personnel file on-site and made available during SCDSS monitoring visits. Experience documented on the form may be accumulated through work with the current contractor and/or other licensed in-home care providers, provided that evidence such as work records, applications, or resumes can be produced to support the claimed experience. The SCDSS Adult Advocacy Director or designee will sign and date the form upon verification, and a copy will be returned to the contractor's business address on file. This certification requirement applies to contractors providing services under the APS, ETPS, Homemaker, CNAs, and PCAs program categories in South Carolina.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attach A_ DSS Form 2433.pdf | ||
| Amendment 1.docx | DOCX document | |
| Attach D_DSS Form 3797.pdf | ||
| 5400029256.pdf | ||
| Attach B_DSS Form 30141.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .