Exhibit_C_Service_Providing_Agency_Staffing_Roster_Template_2024.03.19__2_.xlsx
XLSX spreadsheet 1 MB Posted
- Attached to
- Master Agreement AZ|CTR077022
- Contract number
- CTR077022
- Issued by
- Arizona
About this file
This document is an Excel template titled "Exhibit C: Service Providing Agency Staffing Roster" for the Arizona Early Intervention Program (AzEIP), administered by the Arizona Department of Economic Security. The template is a comprehensive staffing tracking tool designed for early intervention service providers to document personnel details across multiple regions in Arizona. It requires quarterly submission and updates within five business days of any personnel changes, covering administrative and direct service staff working under the AzEIP contract.
The staffing roster template captures detailed information for each staff member, including contact details, professional credentials, employment dates, regional assignments, and specific work hours. The document covers staffing for nine primary regions and additional regions (10-22), with tabs for administrative staff, regional staff, and team meeting information. Staff roles include Service/Support Coordinators, Developmental Special Instructionists, Occupational Therapists, Physical Therapists, Speech and Language Pathologists, Psychologists, and Social Workers. The template mandates tracking critical information such as Central Registry approval dates, fingerprint clearance card expiration, license details, and specialties, ensuring comprehensive personnel documentation for early intervention services.
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Instructions AzEIP Service Providing Agency Staffing Roster Instructions
| Use this template to identify contact information for all of your agency's early intervention staff who work under the AzEIP contract, including all subcontractors and administrative staff. |
| This template must be completed and submitted to AzEIPQualityImprovement@azdes.gov on: |
* The first week of each calendar quarter; AND
* Within five (5) business days of any Service Providing Agency Personnel changes who is working under this contract; AND
* Upon request by AzEIP.
1) To get started, click on the first tab named "Service Providing Agency Detail".
A) Enter your agency name, mailing address, location of child records, and agency website.
* If child records are maintained electronically please specify such.
B) If your agency uses subcontractors, please identify each one on a separate line.
2) Next, click on the "Service Providing Agency Admin" tab.
A) Enter the first and last name (including any aliases, i.e. Matthew "Matt"), role, phone number, email address, fax number, date Central Registry was approved, fingerprint clearance card expiration date, employment start/end date, subcontractor agency name (if applicable), and supervisor for any employee NOT providing direct early intervention services to families, including but not limited to the following roles:
* Program Director;
* Referral Coordinator;
* Data Manager;
* Receptionist;
* Finance Manager;
* Contract Manager;
* Supervisor.
B) When an employee resigns or is terminated, please enter the their last day of employment on this template.
3) Next, click on the "Region (#) or District Staff" tab.
A) Rename this tab to reflect the region number or district (i.e., "Region 17 Staff", "District South Staff")
* Duplicate this tab for all contract regions awarded and rename as instructed above.
B) Enter the first and last name (including any aliases, i.e. Matthew "Matt"), role, specialty, phone number, email address, fax number, date Central Registry was approved, fingerprint clearance card expiration date, region start/end date, team number(s), hours worked weekly in region, subcontractor agency name (if applicable), and supervisor for any employee who provides services to families, including but not limited to the following roles:
* Service/Support Coordinator (SC);
* Developmental Special Instructionist (DSI);
* Occupational Therapist (OT);
* Physical Therapist (PT);
* Speech and Language Pathologist (SLP);
* Psychologist (PSY);
* Social Worker (SW).
C) Indicate in the "Specialty" column, any expertise a team member has (i.e., Multilingual, Feeding, Assistive Technology expertise, etc.)
D) Indicate in the "Region/ District Start Date" and "Region/ District End Date" columns the dates of employment in the identified region.
E) Indicate in the "Total Weekly Hours" column the number of hours per week that each staff works, per region and team.
* If an employee works in more than one (1) region, their name will need to be entered on the respective "Region (#) or District Staff" tab, specifying the hours worked in that one (1) region. (i.e. a staff may be a full time employee but work 5 hours in Region 1 and 35 hours in Region 5, this will need to be separated on two tabs).
* If an employee works in a region that has multiple teams, separate the teams and hours worked by commas if necessary.
(i.e. Team 1 = 10hrs, Team 2 = 5hrs, Team 3 = 25hrs)
4) Next, click on the "Team Meeting Information" tab.
A) Team Meetings shall be held on a weekly basis unless prior approval is received by AzEIP.
B) Enter the Region #, Team #, Weekday and Time that the team meeting occurs, Conference Call-in Information, Location, and Facilitator name for all team meetings at your agency.
Service Providing Agency Detail Agency Name Agency Mailing Address Main Physical Address where Child Records are located Agency Website
Service Providing Agency Contact Information
Service Providing Agency Admin First Name Last Name Role Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date Employment Start Date Employment End Date Subcontracting agency (if applicable) Supervisor Name
Service Providing Agency Administrative Staffing Roster
Region 1 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 2 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 3 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 4a First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 4b First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 5 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 6 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 7 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 8 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 9 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Regions 11-14 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Region 15-16 First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Regions 10 & 17-22 (North) First Name Last Name I-Teams User ID Professional Discipline Type of Degree (ex: Bachelor's) Field of Study Education Plan (Y/N) Specialty Telephone Number Primary Email Address Fax Number Central Registry Approval Date Fingerprint Clearance Card Expiration Date License Expiration Data Region/ District Start Date Region/ District End Date Team(s) Total Weekly Hours (per team) Subcontracting agency (if applicable) Supervisor Name User Role(s) in I-Teams
Service Providing Agency Staffing Roster
Team Meeting Information Region # Team # Day of the Week Time Conference Call Information Location Team Meeting Facilitator Name
Team Meeting Information image1.png
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