Scribd Logo
Upload

Welcome to Scribd!

  • 62 views

    2017-2018 Paperwork

    Uploaded by

    April
    This document is a form from the Alabama Department of Human Resources used to request a clearance check of the state's Child Abuse/Neglect Central Registry. It collects identifying information about an individual who will provide unsupervised care or supervision of children. The form requests information such as the name, date of birth, addresses, and spouse/child information of the individual. It authorizes DHR to search the registry and release any matches to the requesting agency. Upon completion, DHR will indicate on the form if a substantiated abuse/neglect report was found against the individual in the registry and provide additional details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    2017-2018 Paperwork

    Uploaded by

    April
    62 views1 page
    This document is a form from the Alabama Department of Human Resources used to request a clearance check of the state's Child Abuse/Neglect Central Registry. It collects identifying information about an individual who will provide unsupervised care or supervision of children. The form requests information such as the name, date of birth, addresses, and spouse/child information of the individual. It authorizes DHR to search the registry and release any matches to the requesting agency. Upon completion, DHR will indicate on the form if a substantiated abuse/neglect report was found against the individual in the registry and provide additional details.

    Original Description:

    Please be sure to complete ALL items.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a form from the Alabama Department of Human Resources used to request a clearance check of the state's Child Abuse/Neglect Central Registry. It collects identifying information about an individual who will provide unsupervised care or supervision of children. The form requests information such as the name, date of birth, addresses, and spouse/child information of the individual. It authorizes DHR to search the registry and release any matches to the requesting agency. Upon completion, DHR will indicate on the form if a substantiated abuse/neglect report was found against the individual in the registry and provide additional details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    62 views1 page

    2017-2018 Paperwork

    Uploaded by

    April
    This document is a form from the Alabama Department of Human Resources used to request a clearance check of the state's Child Abuse/Neglect Central Registry. It collects identifying information about an individual who will provide unsupervised care or supervision of children. The form requests information such as the name, date of birth, addresses, and spouse/child information of the individual. It authorizes DHR to search the registry and release any matches to the requesting agency. Upon completion, DHR will indicate on the form if a substantiated abuse/neglect report was found against the individual in the registry and provide additional details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Print Form

    ALABAMA DEPARTMENT OF HUMAN RESOURCES


    CHILD ABUSE / NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE
    PRINT OR TYPE in black or blue ink. Additional information regarding the CA/N Central Registry is on the back of this form.
    ** See instructions for the address to use when submitting this form. **
    Requesting Person or Agency/Organization Check All That Apply
    Mailing Address Child Placing Agency
    Residential Child Care Facility
    Child Day / Night Care Center

    Telephone Number ( ) Email: Family Day / Night Care Home


    PRINT Requestors Name Exempt Child Day Care Center
    Requestor Date Medicaid Rehab. Provider
    Signature DHR Vendor
    Witness Date Other (Please Specify)
    Signature
    _________________________________

    The person whose name and identifying information, printed or typed below, will provide unsupervised care and
    supervision of children as an employee volunteer other. This persons specific job/role is or will be:
    _________________________________________________________________________________________________
    _________________________________________________________________________________________________

    Name _____________________________________________ Sex Male Race ___________ DOB ___/___/______


    Last First Middle Female
    Current Mailing Address __________________________________________________________________________
    Alias, Maiden & Prior Married Name(s) ______________________________________________________________
    Name & DOB of Spouse & Former Spouse(s) _________________________________________________________
    Name & DOB of Children / Stepchildren ______________________________________________________________
    Alabama counties where person has lived and/or worked _________________________________________________
    Attach additional pages as needed to provide all information requested above.
    To be completed by person being cleared
    I authorize the Alabama Department of Human Resources to release information contained in the Child Abuse / Neglect Central
    Registry about me to the above named person/agency/organization. I hereby waive any right to any review or hearing to which I may
    otherwise be entitled. I further release the Department of Human Resources, its officers, and employees from any and all claims
    arising out of or in any way connected to the release or dissemination of any information concerning me.

    _________________________________ ________________ _________________________________ ________________


    Signature Date Signature of Witness Date

    To be completed by DHR
    A search of the Alabama Child Abuse / Neglect Central Registry has been completed with the information provided to
    determine if the person identified above has been named as being responsible for child abuse or neglect in Alabama.
    DHR releases only that information which is necessary to discover or prevent child abuse / neglect.
    Substantiated report (i.e., indicated) located. See attached information.
    Type Report: Physical Abuse Neglect Sexual Abuse Mental Abuse / Neglect
    No report located.
    Request Denied ______________________________________________________________________________
    Other _________________________________________________________________________________________
    _________________________________________________________ ______________________________________
    Office of Child Protective Services Date Completed

    DHR-FCS-1598 (Revised December 2009)

    You might also like