Exhibit_C_Service_Providing_Agency_Staffing_Roster_Template_2024.03.19.xlsx

XLSX spreadsheet 1 MB Posted Jul 1, 2025

Attached to: Master Agreement AZ|CTR077020
Contract number: CTR077020
Issued by: Arizona

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Written by GovTribe AI · Oct 8, 2025

This document is an Excel template for the Arizona Early Intervention Program (AzEIP) Service Providing Agency Staffing Roster, used to track personnel information for early intervention staff across multiple regions in Arizona. The template is designed for service providing agencies to document detailed information about their administrative and direct service staff, including subcontractors working under the AzEIP contract with the Arizona Department of Economic Security.

The staffing roster requires comprehensive documentation for each employee, including personal and professional details such as contact information, role, professional credentials, license expiration dates, fingerprint clearance card details, employment dates, weekly hours worked, and regional assignments. The template covers 22 distinct regions/districts and requires quarterly submission, with updates required within five business days of any personnel changes. Staff roles include Service/Support Coordinators, Developmental Special Instructionists, Occupational Therapists, Physical Therapists, Speech and Language Pathologists, Psychologists, and Social Workers, with provisions for noting individual staff specialties and expertise.

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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