Sheet 1: Instructions

	
	

		

 
	
	
	

		
Connecticut Department of Social Services
	
	

		
Home and Community Based Services
	
	

		


	
	

		
HCBS Provider Employee Training Roster Form
	
	

		


	
	

		
Purpose
	
	

		
The HCBS Provider Employee Training Registration Form is a document for providers to register their employees for HCBS ARPA Training. Once registered, each employee will be assigned a learner identifier, enrolled in the HCBS Racial Equity Training Program and notified of their creditials by the email address provided.
	
	

		


	
	

		
Information to Include
	
	

		
The information required to enroll a group of provider employees is the Provider's agency name, the Provider's ID and for each employee to be trained; their first name, last name and an email address.
	
	

		


	
	

		
How the form is used
	
	

		
This form will be used to enroll a provider's employees in to the HCBS Racial Equity Training Course, which is an eligibility component of the HCBS ARPA Value Based Payment incentive.
	
	

		


	
	

		
Instructions
	
	

		
Enter the information defined below in the corresponding fields on the Learn Center Personnel Imports tab. The DSS LearnCenter will return incomplete or inaccurate enrollment forms to the sender with a copy to a staff member at DSS Community Options. It is the responsibility of the submitting agency to return an accurate and complete form to the DSS LearnCenter. These enrollments cannot be processed with incomplete or inaccurate information.
	
	

		


	
	

		
Fields
	
	

		
Provider Agency Name -  Enter the legal entity name of the provider's agency. If doing business as, enter the dba name in parenthesis at the end.
	
	

		
Total Number of Employees in the Agency - Enter the total number of employees in the Home and Community Based Services (HCBS) provider's agency.
	
	

		
Agency Training Point of Contact (PoC) Name - Enter the name of the primary point of contact in the provider agency for support of this training program.
	
	

		
Agency Training PoC Email - Enter the email address of the primary point of contact in the provider agency for support of this training program.
	
	

		
Agency Training PoC Phone - Enter the phone number of the primary point of contact in the provider agency for support of this training program.
	
	

		
Line No. (Column A) - Enter a sequential number for each employee to be listed. To add additional rows to the  blue/white lined table, select any empty field in the bottom empty row of the table, right click, select Insert, select Table Row Below. Repeat for as many additional rows as required.
	
	

		
First Name (Column B) - Enter the first name of the employee to enroll for training.
	
	

		
Last Name (Column C) - Enter the last name of the employee to enroll for training.
	
	

		
AVRS (Medicaid) ID (Column D) - Enter the AVRS (Medicaid) ID ....
	
	

		
Learner Email Address (Column E) - Enter the email address of the employee to be enrolled for training. Enrollment instructions will be sent to the employee at this email address.
	
	

		
Manager/ Supervisor? (Yes/No) (Column F) - Enter YES if the employee is a manager or supervisor and NO if not.