Staffing Pattern Program license number____________ Dat

Staffing Pattern Program license number____________ Date completed ___ /___ /___Not PublicDirections: Complete I and II for each day of the week in which the center is in operation. Indicate if information applies for multiple days of operation.Program name: ______________________________________ Location: ________________________________________________Day(s) of week: _____________________________________I.6:007:008:009:0010:0011:0012:001:002:003:004:005:006:00I. Use a separate line for each staff member working directly with participants. Indicate volunteers if included in staff ratio. Note the name of the staff member or volunteer on the line. Indicate with an asterisk (*) those staff members trained in first aid and treatment of obstructed airways and certified in cardiopulmonary resuscitation.Sample: M. Jones II.II. Total number of participants present each hour.a. Number of participants deemed capable of taking appropriate action for self-preservation in an emergencyb. Number of participants deemed incapable of taking appropriate action for self-preservation in an emergency.ssDHS-5118-ENG 6-07(was MS-2114)
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