Form 3016 "Administrator Licensing - Reference for an Applicant" - Texas

What Is Form 3016?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3016 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3016 "Administrator Licensing - Reference for an Applicant" - Texas

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Form 3016
October 2020
Administrator Licensing - Reference for an Applicant
Use this form to provide a reference for a person who is applying for an administrator's license.
Instructions: This form must be completed solely by you (the person giving the reference). Add additional pages, as needed.
The information entered onto this form must be handwritten. Only original, handwritten references received on this
form are accepted. A letter may not be substituted for this form. If you supervised or worked with the applicant, you must also
complete the cells that contain an asterisk (*). Do not use whiteout.
Directions: After completing this form, mail it to:
Texas Health and Human Services Commission
Administrator Licensing
P.O. Box 16017
RCCL Mail Code 1732
Houston, TX 77222
Reference’s Information
Name (person giving the reference):
*Job Title:
*Address:
*Telephone Number:
Applicant's Name:
*Applicant's Job Title (when you worked with the applicant, if applicable):
*Organization's Name (where you worked with the applicant, if applicable):
*Applicant's Date(s) of Employment With You:
*Are you a current or past supervisor who can verify that the applicant has at least one year of full-time experience in management or
supervision of residential child care or child-placing personnel and programs within the past 10 years? If yes, complete question 1a in
addition to other questions. If no, begin with question 1b.
Yes
No
Applicant’s Information
1a) Describe the applicant’s supervisory or management responsibilities when working with you. In your description, include:
• The start and end dates the applicant held the supervisory or management position;
• How the applicant’s responsibilities related to the implementation of the residential child care or child-placing program; and
• Whether the applicant was responsible for assigning duties, hiring, disciplining, rewarding, approving leave requests and conducting
formal employee evaluations (include the number and type of personnel positions that the applicant supervised).
1b) Describe the applicant's job responsibilities when working with you. If applicable, include number of staff and the types of positions that the
applicant supervised.
Form 3016
October 2020
Administrator Licensing - Reference for an Applicant
Use this form to provide a reference for a person who is applying for an administrator's license.
Instructions: This form must be completed solely by you (the person giving the reference). Add additional pages, as needed.
The information entered onto this form must be handwritten. Only original, handwritten references received on this
form are accepted. A letter may not be substituted for this form. If you supervised or worked with the applicant, you must also
complete the cells that contain an asterisk (*). Do not use whiteout.
Directions: After completing this form, mail it to:
Texas Health and Human Services Commission
Administrator Licensing
P.O. Box 16017
RCCL Mail Code 1732
Houston, TX 77222
Reference’s Information
Name (person giving the reference):
*Job Title:
*Address:
*Telephone Number:
Applicant's Name:
*Applicant's Job Title (when you worked with the applicant, if applicable):
*Organization's Name (where you worked with the applicant, if applicable):
*Applicant's Date(s) of Employment With You:
*Are you a current or past supervisor who can verify that the applicant has at least one year of full-time experience in management or
supervision of residential child care or child-placing personnel and programs within the past 10 years? If yes, complete question 1a in
addition to other questions. If no, begin with question 1b.
Yes
No
Applicant’s Information
1a) Describe the applicant’s supervisory or management responsibilities when working with you. In your description, include:
• The start and end dates the applicant held the supervisory or management position;
• How the applicant’s responsibilities related to the implementation of the residential child care or child-placing program; and
• Whether the applicant was responsible for assigning duties, hiring, disciplining, rewarding, approving leave requests and conducting
formal employee evaluations (include the number and type of personnel positions that the applicant supervised).
1b) Describe the applicant's job responsibilities when working with you. If applicable, include number of staff and the types of positions that the
applicant supervised.
Form 3016
Page 2 / 10-2020
Applicant's strengths, qualities or abilities relevant to working as a licensed administrator:
Applicant's areas of weakness relevant to working as a licensed administrator:
Other comments about the applicant relevant to his or her ability to work as a licensed administrator:
Privacy Statement
HHSC values your privacy. For more information, read our privacy policy online at:
https://hhs.texas.gov/policies-practices-
privacy#security.
Signature
I certify that the information that I provided on this form contains no willful misrepresentation or falsification and is true and
complete to the best of my knowledge and belief.
I believe that the applicant is competent to work as the following. (If you agree, place a mark next to the license or licenses that
the applicant is applying for.)
Licensed Child Care Administrator
Licensed Child Placing Agency Administrator
Signature (Person Giving the Reference):
Date Signed
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