Attachment B.pdf

South Carolina Department of Social Services

CONSENT TO RELEASE INFORMATION

With my signature below, I consent for the South Carolina Department of Social Services to conduct a one-time search of the records indicated below to determine whether they contain information that I was the perpetrator of harm to a child and to release information found to the individual/organization named below.

I understand that the information provided may prove to be unfavorable to me. I agree to hold the South Carolina Department of Social Services and its staff harmless from liability associated with release of information requested on this form. If it appears to me that the information has not been updated or is otherwise inaccurate, I agree to notify the Department immediately.

SECTION I. Purpose for Request

A. I am requesting a search of the Central Registry of Child Abuse and Neglect and the Department’s database of records of Child Abuse and Neglect cases in connection with:

nn becoming or remaining a foster parent or potential adoptive parent; or nn becoming or remaining an employee of or a member of the state or a local foster care review board; or nn becoming an employee or volunteer for the South Carolina Guardian ad Litem Program or Richland County CASA.

B. nn I am requesting a search ONLY of the Central Registry of Child Abuse and Neglect for a purpose of .

SECTION II. Mail Results To:

ATTN:

TEL. NO:

SECTION III. Central Registry Check Fees: Please R appropriate box and include payment. Check or Money Order (NO

CASH).

nn Non-Profit Entities………………………….$8.00 nn Name Changes…………………............$8.00 nn For-Profit Entities…………………..……. $25.00 nn Other (Individuals, etc.).…….................$8.00 nn State Agencies………………………..........$8.00 nn Private Adoption Investigations…........$25.00 nn Schools……..............................................$8.00

SECTION IV. Please print legibly or type the following: First, Middle and Last Name (NO INITIALS)

Name: DOB: Sex: Race:

Maiden/Aliases: Name Change:

Place of Birth: SSN: (See instructions)

Current Address: Previous Address: (See instructions)

SECTION V. Your signature MUST be witnessed or notarized. Please mail appropriate payment and form for processing to:

South Carolina Dept. of Social Services, ATTN: Cashier, 1535 Confederate Avenue, P.O. Box 1520, Columbia, SC 29202-1520.

SECTION VI. RESULTS: THIS SECTION IS TO BE COMPLETED ONLY BY AUTHORIZED DSS EMPLOYEES OF THE

DEPARTMENT.

nn The name is not included as a perpetrator on the Central Registry of Child Abuse and Neglect.

nn The request has been received. Additional research will be required to respond to the request. Thirty to sixty days may be required. Please call if you have any questions.

nn The name is included as a perpetrator on the Central Registry of Child Abuse and Neglect.

nn The name is included as a perpetrator in the Department’s database of records of child abuse and neglect cases. See attached correspondence.

DSS Form 3072 (AUG 13) Edition of SEP 08 is obsolete.

Signature of Applicant Date

Signature of Notary or Witness Date

Authorized DSS Employee Date

INSTRUCTIONS FOR DSS FORM 3072 – CONSENT TO RELEASE INFORMATION

PLEASE DO NOT ALTER THIS FORM IN ANY WAY

SECTION I: Purpose for Request: To provide authorization for the SC Department of Social Services to conduct a search of the State Central Registry of Child Abuse and Neglect and/or the DSS Database and to release results. Please indicate the purpose of the search by checking R in the appropriate box.

SECTION II: Mail Results To: Please ensure that you type or stamp the return address next to, “MAIL RESULTS TO,” on this form. Please include the contact person’s name and telephone number.

SECTION III: Central Registry Fee: Please check R appropriate fee box.

SECTION IV: Please type or print legibly the following information:

• Name: Provide complete spelling of name to include the first, middle and last name - NO INITIALS.

• Name Change: List the new name(s).

• Date of Birth: Month/Day/Year

• Sex: (Self Explanatory)

• Race: (Self Explanatory)

• Social Security Number: All the information requested on this form is necessary in order to conduct a thorough search. Providing your Social Security Number (SSN) is optional, but it is recommended that you provide your SSN to assist with the research. Your SSN will be used only to conduct what we hope will be a thorough central registry/data base check and will not be given to any person than indicated agency or entity.

• Place of Birth: Provide the name of the State you were born in.

• Current Address: Provide your current residence.

• Previous Address: If current address is less than 7 years; list other addresses, States, Countries you have resided in for the past seven years. Use separate sheet if necessary.

SECTION V: Mail payment; completed Form 3072 Consent to Release Information, and a stamped addressed envelope to:

South Carolina Department of Social Services Attention: CASHIER

1535 Confederate Avenue P.O. Box 1520

Columbia, SC 29202-1520

• Signature of Applicant: Requesting the applicant’s original signature for a one-time search of the State Central Registry of Child Abuse and Neglect and/or the DSS Database and to release results.

• Signature of Witness or Notary: The applicant’s signature must be witnessed or notarized prior to submitting for processing.

PLEASE CALL (803) 898-7229 IF YOU NEED ASSISTANCE COMPLETING THIS FORM.

After receipt by cashier and processing of payment, the Central Registry/DATA BASE check will be completed by authorized DSS personnel in the Division of Human Services.

DSS personnel in the Division of Human Services must do the following:

1. Conduct Central Registry check and/or Database search in accordance with Section I. A or B.

2. Check appropriate results box.

2. Sign and date form; stamp, “confidential” on envelope and mail to return address, Section II.

Distribution Results of the search will be sent ONLY to the individual or organization specified in Section II of this form.

DSS Form 3072 (AUG 13) PAGE 2