ࡱ>  yxbjbj 4~xx8A;v)p4VT,(((((((*-(Z|(G0)((r9'TU69(P\7%Y('u(F)0v)'v.v.9(v.9(<((v)v. :  The Missouri Department of Health and Senior Services (DHSS) and  FORMTEXT      , hereinafter referred to as Provider, do hereby enter into the following agreement to identify roles and responsibilities related to utilizing the Family Care Safety Registry (FCSR) Internet Background Screening Request System. The following terms are agreed upon as follows: The DHSS shall: Grant access to the FCSR Internet Background Screening System to eligible employees of Provider who is licensed or contracting with the DHSS. Access shall be used for the sole purpose of meeting legal requirements for background screening of employees. Provide ongoing user support to Provider employee. Terminate access to the FCSR Internet Background Screening System to any Provider employee who has not utilized their access for thirty (30) consecutive days. The Provider shall: Ensure that all Provider employees requesting access to the FCSR Internet Background Screening System are registered with the FCSR and are not listed on any background screening database accessed by the FCSR. Request access for individuals who are employed in good standing with Provider in a direct employer-employee relationship. Ensure that Provider shall notify DHSS within 24 hours of any change in Provider employees employment status requiring removal/replacement of the Provider employee currently permitted access. Failure to report changes within designated timeframe may result in termination of Memorandum of Agreement. Ensure that information obtained from the FCSR Internet Background Screening System is obtained for employment purposes only as identified in section 210.921, RSMo, and understand that misuse of information is a class B misdemeanor. Ensure that confidential information obtained through the FCSR Internet Background Screening System is protected as required by applicable state and federal laws and accept liability for any and all breaches of confidentiality. Ensure that Provider employees shall not share passwords issued by DHSS with any other individual. Failure to comply with this provision will result in immediate termination of this agreement. Complete the attached organization/facility information sheet for information to be maintained in the FCSR database, and communicate changes in information to the FCSR in a timely manner. Either party may terminate this agreement with 30 days prior written notice. The parties hereto have signed this Memorandum of Agreement on the date indicated. PROVIDER Authorized SignatureTitle  FORMTEXT       Provider/Agency Name  FORMTEXT       Date  FORMTEXT  DATE 7/3/20121/25/2006Provider License/Contract Number  FORMTEXT      Provider Licensing Agency  FORMTEXT      DEPARTMENT OF HEALTH AND SENIOR SERVICESAuthorized SignatureTitleDivisionDate  Provider/Agency Name (Include DBA name, if applicable.):  FORMTEXT       Parent Company Name (if applicable):  FORMTEXT       Mailing Address:  FORMTEXT       Street Address or PO Box  FORMTEXT       City  FORMTEXT     FORMTEXT        FORMTEXT       State Abbrev. ZIP Code County Telephone: Fax: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      Main Contact Information:  FORMTEXT       Name and Title Telephone Number for Main Contact (if different than above): (  FORMTEXT     )  FORMTEXT     -  FORMTEXT  o p P Q n*+xyŶ̥̜ؖؖ؍ؖބ{pi[pjM.hB^5U\ hB^5\jhB^5U\hB^5CJ\hB^5CJ\hhWCJ hWCJh hWCJ!jhW>*CJUmHnHuj1-hW>*CJU hW>*CJjhW>*CJU hWCJ hB^CJhB^jhB^UjhB^CJUmHnHu o p ~ P Q e 6 n*+xy$Ifh^hgdW & FgdW & FgdWgdW$a$$Ifokd-$$Ifl4PP((  064 laf4p   >@TVXbdfrtv$&(24ݽԳˇ}wj}Z}jhB^CJUmHnHuj0hB^CJU hB^CJjhB^CJU hB^CJhB^5\mHnHuj/hB^5U\h5\mHnHuhWhB^CJ\jR/hB^5U\hB^5CJ\hB^5CJ\ hB^5\jhB^5U\ jhB^5U\mHnHu#<>fhrt$Ifskd.$$Ifl4Z0P(^^064 laf4 6jlwne $IfgdW $IfgdW $IfgdW$If$Ifskd:0$$Ifl40P(^^064 laf446hjln ">@BDFLڸqcNq)jiah;h 5>*CJUaJh;h 5>*CJaJ#jh;h 5>*CJUaJ h;h h j84h Ujh UmHnHuh hB^CJaJhB^5CJ\hB^5CJ\jhB^UmHnHuj?1hB^UhB^jhB^UhEhWCJhW hhW hB^CJ$Ifskd1$$Ifl40P(^^064 laf4 $IfokdR2$$Ifl4P((  064 laf4p  "4>$Ifskd3$$Ifl40P(^^064 laf4>@BHJL .0R`|||^gd gd skd3$$Ifl40P(^^064 laf4 "68:> &(,.RThjlpRXZ^`pƻƭƻƭƻtltƭh CJaJh;h CJaJ)jQbh;h 5>*CJUaJ)jah;h 5>*CJUaJh h;h 5>*CJaJh 5>*CJaJ#jh;h 5>*CJUaJh 5>*CJaJmHnHu.jh;h 5>*CJUaJmHnHu">JL2prJDLDDEEEEEFF'F;F $IfgdB^gd ^gd &,.>HJLNbdfjlprإq\J\#jch 5>*CJUaJ(jh 5>*CJUaJmHnHu#j9ch 5>*CJUaJjh 5>*CJUaJh CJaJh;h CJaJh 5>*CJaJh 5>*CJaJmHnHu.jh;h 5>*CJUaJmHnHu#jh;h 5>*CJUaJ)jbh;h 5>*CJUaJ"(*02<LTnp˳˘wwseSe>SeSe)jdh=h 5>*CJUaJ#jh=h 5>*CJUaJh=h 5>*CJaJh h CJaJh;h CJaJhEdFh 5>*CJaJh 5>*CJaJh 5>*CJaJmHnHu.jh;h 5>*CJUaJmHnHu#jh;h 5>*CJUaJ)j!dh;h 5>*CJUaJh;h 5>*CJaJ "&(<>HPRfhr|~ʵتʕʀkتgU#jh;h 5>*CJUaJh )jfh=h 5>*CJUaJ)j=fh=h 5>*CJUaJ)jeh=h 5>*CJUaJh 5>*CJaJ)jieh=h 5>*CJUaJh=h 5>*CJaJ#jh=h 5>*CJUaJ)jdh=h 5>*CJUaJ ˳˘򍅍sasLasas)jgh=h 5>*CJUaJ#jh=h 5>*CJUaJh=h 5>*CJaJh h CJaJh;h CJaJh 5>*CJaJh 5>*CJaJmHnHu.jh;h 5>*CJUaJmHnHu#jh;h 5>*CJUaJ)jgh;h 5>*CJUaJh;h 5>*CJaJ DDD"D$D8D:D*CJUaJh;h 5>*CJaJ#jh;h 5>*CJUaJh (jh 5>*CJUaJmHnHu#jhh 5>*CJUaJjh 5>*CJUaJh 5>*CJaJ)jYhh=h 5>*CJUaJUh=h 5>*CJaJ#jh=h 5>*CJUaJ)jgh=h 5>*CJUaJ     ext.  FORMTEXT       Email Address (optional):  FORMTEXT       Which type(s) best describe your organization or facility? (Check all that apply.)  FORMCHECKBOX  Child Care Center FORMCHECKBOX  Adult Day Care FORMCHECKBOX  Home Health Agency FORMCHECKBOX Family Child Care Home/Group Home FORMCHECKBOX Assisted Living Facility FORMCHECKBOX Hospice FORMCHECKBOX Child Placement Service (Adoptive/ FORMCHECKBOX Skilled Nursing Facility FORMCHECKBOX Hospital: LTAC or Swing Bed Foster Care) FORMCHECKBOX Nursing Facility FORMCHECKBOX Other Long Term Care Provider FORMCHECKBOX Childrens Home/Residential Facility FORMCHECKBOX Residential Care Facility FORMCHECKBOX General Hospital FORMCHECKBOX State or Local Government Agency FORMCHECKBOX Intermediate Care Facility FORMCHECKBOX Mental Health/Psychiatric  FORMCHECKBOX School: K 12 FORMCHECKBOX Intermediate Care Facility/MR Hospital FORMCHECKBOX School: College/Technical/University FORMCHECKBOX Personal Care: CDS/CIL FORMCHECKBOX Other Health Care Provider FORMCHECKBOX Non-Emergency Medical Transport FORMCHECKBOX Personal Care: In-Home Svcs. FORMCHECKBOX Other (Please list):  FORMTEXT       FORMCHECKBOX Personal Care: HCY/PDW/DDD/Oth. If more than one type selected above, which one is primary? (Please list.)  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