List the name, title, SSN, and business address of all managing employees below as defined in 42 CFR 455.101.

Managing Employee – indicates a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency.

Name

• Enter the First and Last Name.  Middle Initials are optional in this field.

• Upon First and Last Names (Middle Name if entered, as well) being added to the grid as a record, the first, middle, and last names will display in the grid as Name in following format:  Last Name, First Name  Middle Name (if entered), ex  Kennedy, John Fitzgerald

Title

• Select the appropriate title from the drop-down box.  See Table 1

DOB

• Enter the Date of Birth

• Age cannot be greater than 100 years of age

SSN

• Enter the Social Security Number

Address

• Enter the address information in this field

City

• Enter the city for the applicable address

State

• State defaults to Kentucky but is editable

• Select the state from the drop down box

Zip Code

• Enter the appropriate zip code for the applicable address entered

Zip+4

• If known, enter the appropriate +4 Zip code

County

• Enter the corresponding county for the applicable address entered

• If  state is not Kentucky, the default county should be “Out of State”

• This is a required field for ALL physical addresses

If fields are entered then N/A is checked, the data entered will be cleared

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page