• License number
  
• Facility name and address
• Facility ID number (if known)
  
• Brief description of request
• Include end date of prior person in the role and start date for the current person in the role
  
• ​Contact information (name, title, phone number, and e-mail address)
  
• Emergency Contact Information (name, email, alternate email. phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN​ (https://www.calhospitalprepare.org/post/california-health-alert-network-cahan)
  
• Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
  
• Signature

Section H – Facility Information Sheet

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

• Facility name
• Facility address

• Facility type
• Individual’s nature and dates of involvement
• Entity name, type, and Employer Identification Number (EIN)