<p> CRIMINAL BACKGROUND STUDIES EMPLOYEE LIST</p><p>Client Name:</p><p>Employer:</p><p>Co-employer (if applicable)/If using Agency with Choice (typically managing party):</p><p>Names of all staff persons, paid or unpaid, on the plan who are required to have a background study because they work directly with the client.</p><p>NOTE: Persons on the plan that work for a company that we can reasonably believe have already passed a criminal background study completed by that company, are not required.</p><p>1. 11.</p><p>2. 12.</p><p>3. 13.</p><p>4. 14.</p><p>5. 15.</p><p>6. 16.</p><p>7. 17.</p><p>8. 18.</p><p>9. 19.</p><p>10. 20.</p><p>Case Manager Instructions: Must enter a separate line in SMARTS for criminal background study billing, if there is any direct care staff. SMARTS has appropriate codes/rate. Fill out number of studies needed during this plan date span.</p><p>CLS/DD – CDCS – DAK7172 (09/2012)</p>