TX HHS Form 3016. Administrator Licensing - Reference for an Applicant

Form 3016 is an official document used by the Texas Health and Human Services Commission (HHSC) to evaluate the professional background and suitability of individuals applying for a Child Care Administrator License or a Child Placing Agency Administrator License. This form must be completed by a person who has worked directly with the applicant—typically a supervisor, manager, or colleague who can provide authoritative insights into the applicant’s performance, leadership abilities, and professional conduct.

The purpose of Form 3016 is to give licensing authorities a clear, honest, and detailed professional reference from someone with firsthand knowledge of how the applicant performed in regulated child-care or child-placing settings. Because administrators hold significant responsibility for supervising staff, managing operations, and ensuring child safety, HHSC uses this reference to verify both experience and character.

Purpose and Function of the Form

At its core, Form 3016 serves two major functions:

• Verification of experience: HHSC requires administrators to have documented supervisory or management experience within the last 10 years. The reference must confirm this experience when applicable.
• Evaluation of competence and character: The reference provider describes the applicant’s strengths, weaknesses, and practical job responsibilities, giving HHSC a well-rounded view of their readiness for an administrative role.

Only references submitted using this official form are accepted. A standalone letter cannot substitute it, and emailed versions must come directly from the reference provider’s own email address.

Explanation of Key Sections

Reference’s Information

This section gathers identifying information about the person providing the reference. Because HHSC may contact the reference to verify statements, the information must be complete and accurate. Required items include:

• Name and job title
• Phone number with area code
• Full mailing address

Providing incomplete or unclear information is one of the most common mistakes, which can delay the licensing process.

Applicant Information and Employment Details

The form then asks for details about the applicant’s job title, place of employment, and the dates during which the reference provider worked with them. HHSC uses these details to confirm that the applicant meets regulatory experience requirements.

Supervisory Verification Questions

If the reference was the applicant’s supervisor, they must confirm whether the applicant has at least one year of full-time management or supervision experience in residential child care or child-placing services within the last decade. This is a core statutory requirement under Texas Administrative Code guidelines.

Section 1a: Supervisory and Management Experience

This section requires a detailed narrative describing the applicant’s supervisory role. HHSC expects specific information, including:

• Dates the applicant held supervisory or management duties
• How their work aligned with child-care program operations
• Whether they were responsible for hiring, assigning duties, disciplinary actions, evaluations, and approving leave
• The number and types of personnel supervised

Vague descriptions—such as “supervised staff” without details—often lead to requests for clarification.

Section 1b: Job Responsibilities

If the reference provider was not a supervisor, they must describe the applicant’s job functions. This may include caseload management, direct care responsibilities, participation in compliance activities, or oversight of particular programs.

Applicant Strengths and Weaknesses

This area provides HHSC with an honest evaluation of the applicant’s suitability for administrative work. References should avoid generic statements and instead offer grounded observations, such as decision-making ability, communication skills, adherence to regulatory requirements, and professional conduct under pressure.

Additional Comments

A space is provided for any other information relevant to the applicant’s ability to hold an administrator license. Reference providers often include remarks about reliability, integrity, or notable achievements.

Certification and Signature

The reference provider certifies their statements as true. This creates a legal obligation not to falsify information, as misrepresentation can affect both the applicant’s eligibility and the credibility of the reference provider.

Legal and Regulatory Context

Form 3016 is required under Texas Human Resources Code and the Texas Administrative Code governing licensing of child-care administrators. The state mandates strict oversight of residential and child-placing programs due to the vulnerability of children in care. HHSC uses this form to ensure that administrators meet minimum standards of competence, experience, and ethical conduct.

When Form 3016 Must Be Submitted

• When an individual applies for a Child Care Administrator License.
• When an individual applies for a Child Placing Agency Administrator License.
• When HHSC requests additional verification of experience as part of a renewal or investigation.

The form is not required for unrelated childcare roles, basic caregiver positions, or administrative positions outside licensed programs.

Examples of Real-World Situations

• Example 1: A program director applying for a Child Care Administrator License must submit Form 3016 from their supervisor confirming their past supervisory duties.
• Example 2: A case manager transitioning into a child-placing agency leadership role needs a reference describing their responsibilities and strengths relevant to administration.
• Example 3: An assistant administrator seeking promotion must document their management experience through at least one professional reference.
• Example 4: An applicant trained in another state must provide Form 3016 to verify equivalent experience in Texas-regulated settings.

Documents Commonly Attached or Requested

• Employment verification letters (optional but helpful)
• Organization charts showing supervisory hierarchy
• Job descriptions for clarity on responsibilities
• Copies of licenses or training certificates (if relevant)

Practical Tips for Completing the Form

• Fill out every field completely; HHSC may reject incomplete forms.
• Use clear, specific descriptions when explaining job duties.
• Avoid whiteout—cross out and initial any corrections.
• If sending by email, ensure it is sent directly from the reference provider’s email address.
• Include dates in full (month/day/year) to avoid delays.

Related Forms

• Form 3015 – Application for Administrator License
• Form 2999 – Background Check Authorization
• Form 3000 – Professional Experience Verification

FAQ

• Who is allowed to complete Form 3016? Anyone who has supervised or worked closely with the applicant in a professional child-care or child-placing environment.
• Can a coworker provide the reference if they were not a supervisor? Yes, but they must complete Section 1b instead of 1a.
• Can I send a separate reference letter instead of this form? No. HHSC accepts only this official form.
• What happens if the form is incomplete? HHSC may request additional information, delaying the licensing process.
• Is digital submission allowed? Yes, but only if the email is sent from the reference provider’s own email address.
• Does this form alone guarantee licensure? No. It is one factor among several reviewed by HHSC.

Micro-FAQ (Short Answers)

• Purpose: To provide HHSC with a professional reference for an administrator license applicant.
• Who completes it: A supervisor or colleague who worked with the applicant.
• Deadline: Submitted as part of the license application packet.
• Attachments: Optional supporting documents like job descriptions.
• Where it’s submitted: HHSC Administrator Licensing in San Antonio, TX or by email.
• Mandatory? Yes, for administrator license applications.
• Format: Must use the official form; letters are not accepted.
• Can supervisors verify experience? Yes—required when applicable.
• Is whiteout allowed? No.
• Digital signatures: Allowed if sent directly by the reference provider.

Form Details

• Form Name: Administrator Licensing – Reference for an Applicant
• Form Number: 3016
• Region: Texas, United States
• Agency: Texas Health and Human Services Commission (HHSC)
• Revision Date: September 2022