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CC4C and Pregnancy Care Management Staffing Information

Page One

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Within 30 days of a status change with any CC4C Management or Pregnancy Care Management Supervisor or CC4C or Pregnancy Care Manager position (new hire, position vacancy, position elimination, or other change), please complete and submit this form. This Form may also be used to submit corrected contact information for existing staff.

Person Completing Form

1. Respondent First Name *This question is required.

2. Respondent Last Name *This question is required.

3. Respondent Email Address *This question is required.

4. Effective Date of Submitted Information (mm/dd/yyyy) *This question is required.

Calendar

5. I am reporting one of the following: *This question is required.

New Hire
Updated Info on Current Staff (employee’s first and last name AND STAFF POSITION are required; staff position is required to ensure that the correct state program staff are notified; then complete only the field where updated info is needed)
Staff Vacancy (completion of the employee’s first and last name is required, and will result in their information being removed from the database).

Staffing Information to be submitted:

6. County: *This question is required.

7. Staff First Name *This question is required.

8. Staff Last Name *This question is required.

9. Staff Phone Number - Please enter using the following format: xxx-xxx-xxxx

10. Phone extension, if applicable

11. Staff Fax Number - Please enter using the following format: 999-999-9999

12. Staff Email Address

13. Staff Position:

Supervisor – CC4C
Supervisor – Pregnancy Care Management
Supervisor – CC4C and Pregnancy Care Management
CC4C Care Manager
Pregnancy Care Manager
CC4C and Pregnancy Care Manager
Other Please enter an 'other' value for this selection.