Attachment 13 - AzEIP Central Registy.pdf
PDF 249 KB Posted
- Solicitation number
- BPM000600
- Issued by
- Apache County, Phoenix City, Arizona
About this file
This is a Provider Request Form for Central Registry Background Check issued by the Arizona Department of Economic Security, Division of Developmental Disabilities/Early Intervention (AzEIP). The form is used to request background checks for individuals who will provide direct services to children or vulnerable adults under contracts with the Division. The document serves as a cover sheet and includes multiple request forms that can be submitted simultaneously, with no limit on the number of individuals for whom checks are requested. Contractors and subcontractors must complete all required fields accurately and legibly, including contractor/subcontractor name, solicitation number, employee status (new or existing), contract type (new contract or extension), tracking number, and requestor information. Results are processed within two working days, and requestors can submit completed forms via secure email, fax, or mail to the designated Division addresses.
The form identifies specific disqualifying acts related to child abuse, neglect, and sexual abuse that would result in employment disqualification for direct service positions. Substantiated reports in any of 44 enumerated categories—ranging from child death due to abuse or neglect to various levels of physical abuse, sexual abuse, emotional abuse, and neglect risk levels—preclude employment. For individuals with no substantiated reports, only the requestor receives notification. For those with substantiated reports, the individual, requestor, and contract signatory are notified, with the signatory required to respond within 10 working days confirming the person is not providing direct services. The document includes equal opportunity employment disclosures indicating compliance with civil rights legislation, the Americans with Disabilities Act, and the Genetic Information Nondiscrimination Act.
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Text version
DDD-1703A FORFF (9-15) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities/Early Intervention
(AzEIP)
PROVIDER REQUEST FOR
CENTRAL REGISTRY BACKGROUND CHECK
COVER SHEET
This document and any files transmitted with it are confidential and intended solely for the use of the individual or entity to which they are addressed. If you have received this information in error, please notify the sender and destroy the information. The information contained in the Central Registry and any attached files are intended to be used as a factor to determine qualifications for each Applicant and Administrator for a Contract with the Division and for each person who will provide direct service to a child or vulnerable adult for a Contractor or Subcontractor. The information contained in the Central Registry is confidential and must not be further disseminated or shared.
Please fill out the information below and send this Cover Sheet with the attached Request Form(s). There is no limit to the number of Request Forms (page 2) that may be attached to this Cover Sheet. Information entered in all fields must be accurate, legible, and complete.
Contractor, or Subcontractor Name
Solicitation Number Check all applicable:
New Employee Existing Employee New Contract with DDD Contract Extension
Tracking Number (You must assign a unique combination of numbers and/or letters to track this document and the persons listed on it for a background check. The Tracking Number may include the name of the company but not the name, initials, or SSN for a person listed on this request)
Name of Person Authorized to Submit Request (Requestor)
Requestor’s Email Address Requestor’s Phone Number
Requestor’s Signature Date of Request
SUBMIT YOUR COMPLETED COVER SHEET AND REQUEST FORM(S) VIA ONE OF THE FOLLOWING:
Secure Email to: DDDCentralRegistrySearchRequest@azdes.gov
Fax to: 602-542-8193 – Attn: Central Registry Request
Mail to: Division of Developmental Disabilities Attn: Central Registry Request P.O. Box 6123, Mail Drop 2HC3 Phoenix, AZ 85005
The result(s) of this background check will be processed within two working days and notification will be sent as follows.
1. For persons with no record of substantiated reports of abuse or neglect, the Requestor will be notified.
2. For persons with one or more substantiated report of abuse or neglect, the person, the Requestor and the Signatory on the Contract will be notified.
If a person has a substantiated report of abuse or neglect for a disqualifying act, the Signatory will be required to respond to the Division within 10 working days with a statement verifying that the person is not providing a direct service to a child or vulnerable adult.
Illegible, inaccurate, or incomplete information on the Cover Sheet or Request Form will delay your response from the Division.
See last page for EOE/ADA/LEP/GINA disclosures mailto:DDDCentralRegistrySearchRequest@azdes.gov
REQUEST FOR CENTRAL REGISTRY BACKGROUND CHECK
(All fields must be completed, accurately and legibly.)
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
Reports: Yes Number: [See attached document(s)] No Date of Search:
NAME OF PERSON COMPLETING SEARCH SIGNATURE
PERSON REQUIRING THE CENTRAL REGISTRY BACKGROUND CHECK
NAME ALIAS (Previously used name(s))
SOC. SEC. NO. DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP)
DDD – INTERNAL USE ONLY (Search results)
DISQUALIFICATION ACTS
A person is disqualified from employment in a direct service position if he/she is identified as the subject of a substantiated report for any of the following. View Finding Statement if available.
24 Child death due to alleged abuse or neglect, or suspicious death
25 Injuries requiring emergency medical treatment
27 Child age 24 months is shaken (shaken baby syndrome)
33 Untreated life threatening condition, Infant Doe, Non-organic FTT
37 Imminent harm to child under the age of six (6) due to lack of supervision by parent/caretaker
38 Neglect results in injury/illness requiring emergency medical treatment
39 Imminent harm to child due to health or safety hazards in living environment/exposure to the elements
40 Child diagnosed as suicidal by mental health professions, parent refused to allow treatment
41 Physical evidence of sexual abuse reported by a medical doctor or child reporting sexual abuse within the past seven days
42 Child reporting vaginal or anal penetration or oral sexual contact within past 72 hours and has not been examined
43 Abandoned, no parent willing to provide immediate care for a child and child is with a caregiver unable or unwilling to provide care now
45 Injuries may require medical treatment
46 P3 Injury to child under age six years
50 Living environment presents health or safety hazards to a child under the age of six
51 Sexual conduct/physical injury between children due to inadequate supervision
54 Sexual behavior within the past 8-14 days
55 Child diagnosed by mental health professional with behavior consistent with emotional abuse
56 Abandoned, no parent willing to care for a child, child with caretaker unable or unwilling to care for child less than one week
66 Significant developmental delays due to neglect
69 Attempted sexual behavior or sexual behavior, 14 days to three years r last occur unknown
72 Parent, guardian or custodian suggests or entices child to engage in sexual behavior, no touching
76 Use of child by parent, guardian or custodian for material gain
82 Parent, guardian or custodian sexually abused a child in past, now in home with a child
83 Attempted sexual behavior or sexual behavioral when last occurred more than three years
101 Death of a child due to neglect
111 Death of a child due to physical abuse or suspicious death
201 Physical abuse high risk
202 Physical abuse moderate risk
301 Neglect, high risk
302 Neglect, moderate risk
401 Sexual abuse, high risk
402 Sexual abuse, moderate risk
403 Sexual Abuse, low risk
404 Sexual Abuse, response 4
501 Emotion Abuse, high risk
502 Emotional abuse, moderate risk
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity.
For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
| Contractor Number: |
| Tracking Number You must assign a unique combination of numbers andor letters to track this document and the persons listed on it for a background check The Tracking Number may include the name of the company but not the name initials or SSN for a person listed on this request: |
| New Employee: Off |
| Existing Employee: Off |
| New Contract with DDD: Off |
| Contract Extension: Off |
| Requestors Email Address: |
| Requestors Phone Number: |
| Requestors Signature: |
| Date of Request: |
| SOC SEC NO: |
| DATE OF BIRTH: |
| Reports: Off |
| NAME OF PERSON COMPLETING SEARCH: |
| SOC SEC NO_2: |
| DATE OF BIRTH_2: |
| Reports_2: Off |
| NAME OF PERSON COMPLETING SEARCH_2: |
| SOC SEC NO_3: |
| DATE OF BIRTH_3: |
| Reports_3: Off |
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| SOC SEC NO_4: |
| DATE OF BIRTH_4: |
| Reports_4: Off |
| NAME OF PERSON COMPLETING SEARCH_4: |
| SOC SEC NO_5: |
| DATE OF BIRTH_5: |
| Reports_5: Off |
| NAME OF PERSON COMPLETING SEARCH_5: |
| SOC SEC NO_6: |
| DATE OF BIRTH_6: |
| Reports_6: Off |
| NAME OF PERSON COMPLETING SEARCH_6: |
| SOC SEC NO_7: |
| DATE OF BIRTH_7: |
| Reports_7: Off |
| NAME OF PERSON COMPLETING SEARCH_7: |
| SOC SEC NO_8: |
| DATE OF BIRTH_8: |
| Reports_8: Off |
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| SOC SEC NO_9: |
| DATE OF BIRTH_9: |
| Reports_9: Off |
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| SOC SEC NO_10: |
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| Reports_10: Off |
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| SOC SEC NO_11: |
| DATE OF BIRTH_11: |
| Reports_11: Off |
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| SOC SEC NO_12: |
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| Reports_12: Off |
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| Reports_13: Off |
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| Reports_14: Off |
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| SOC SEC NO_15: |
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| Reports_15: Off |
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| Reports_16: Off |
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| Reports_17: Off |
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| SOC SEC NO_18: |
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| Reports_18: Off |
| NAME OF PERSON COMPLETING SEARCH_18: |
| SOC SEC NO_19: |
| DATE OF BIRTH_19: |
| Reports_19: Off |
| NAME OF PERSON COMPLETING SEARCH_19: |
| SOC SEC NO_20: |
| DATE OF BIRTH_20: |
| Reports_20: Off |
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| SOC SEC NO_21: |
| DATE OF BIRTH_21: |
| Reports_21: Off |
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| SOC SEC NO_22: |
| DATE OF BIRTH_22: |
| Reports_22: Off |
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| SOC SEC NO_23: |
| DATE OF BIRTH_23: |
| Reports_23: Off |
| NAME OF PERSON COMPLETING SEARCH_23: |
| SOC SEC NO_24: |
| DATE OF BIRTH_24: |
| Reports_24: Off |
| NAME OF PERSON COMPLETING SEARCH_24: |
| 24 Child death due to alleged abuse or neglect or suspicious death: |
| 25 Injuries requiring emergency medical treatment: |
| 27 Child age 24 months is shaken shaken baby syndrome: |
| 33 Untreated life threatening condition Infant Doe Nonorganic FTT: |
| 37 Imminent harm to child under the age of six 6 due to lack of supervision by parentcaretaker: |
| 38 Neglect results in injuryillness requiring emergency medical treatment: |
| 40 Child diagnosed as suicidal by mental health professions parent refused to allow treatment: |
| 45 Injuries may require medical treatment: |
| 46 P3 Injury to child under age six years: |
| 50 Living environment presents health or safety hazards to a child under the age of six: |
| 51 Sexual conductphysical injury between children due to inadequate supervision: |
| 54 Sexual behavior within the past 814 days: |
| 55 Child diagnosed by mental health professional with behavior consistent with emotional abuse: |
| 66 Significant developmental delays due to neglect: |
| 69 Attempted sexual behavior or sexual behavior 14 days to three years r last occur unknown: |
| 76 Use of child by parent guardian or custodian for material gain: |
| 82 Parent guardian or custodian sexually abused a child in past now in home with a child: |
| 83 Attempted sexual behavior or sexual behavioral when last occurred more than three years: |
| 101 Death of a child due to neglect: |
| 111 Death of a child due to physical abuse or suspicious death: |
| 201 Physical abuse high risk: |
| 202 Physical abuse moderate risk: |
| 301 Neglect high risk: |
| 302 Neglect moderate risk: |
| 401 Sexual abuse high risk: |
| 402 Sexual abuse moderate risk: |
| 403 Sexual Abuse low risk: |
| 404 Sexual Abuse response 4: |
| 501 Emotion Abuse high risk: |
| 502 Emotional abuse moderate risk: |
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