CSO-1637 (1).pdf

Additional Information ~ If you wish to provide additional information please attach additional pages as necessary.

All information on the form must be typed or printed.

BACKGROUND CHECK AUTHORIZATION

You are being provided this form because you have applied for a position which requires a search of the Arizona Department of Child Safety’s (DCS) Central Registry and a Level 1 Fingerprint Clearance Card issued by the Department of Public Safety (DPS). Both are required by Arizona state law. Your information, upon submission by your employer, will be searched through the DCS Central Registry and the DCS and DPS Fingerprint Clearance Card databases.

ARIZONA DEPARTMENT OF CHILD SAFETY

CSO-1637

(11/19)

Are you currently registered or subject to registration as a sex offender in Arizona or any other jurisdiction?

Are you currently the subject of an investigation of child abuse or neglect in another state or jurisdiction?

Are you currently the subject of an investigation of child abuse or neglect in Arizona?

Provider Name

Reason for Separation

Yes

Yes

Yes

No

No

No

Applicant/Employee/Volunteer Name (Last, First M.I.)

Aliases (Including Maiden Name & Nicknames)

Email AddressPhone No.

Date of Birth (mm/dd/yyyy) Soc. Sec. No.

Position

Date of Separation

Date of HireAddress (No., Street) City State ZIP

Have you ever been the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction that resulted in a substantiated (determined to have occurred) finding?

If Yes to any of the above questions:

Yes No

Eligible for RehireNew Hire RehireVolunteer Separation

What was the allegation(s)?

When was the investigation(s) conducted?

Where was the investigation(s) conducted? (Include state in which the investigation occurred)

Residence History

Have you resided outside of Arizona at any time in the last five years Yes No

If Yes list all states and/or countries you have resided in within the last five years other than Arizona:

Signature of Employee/Applicant

Signature of Witness

Date

Date

Date form Received Date Information Input to Quick Connect Information Input By

For Provider Use Only ~ Information on this form must be input through Quick Connect within 5 days of hire or termination.

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to allow a person with a disability to take part in a program, service, or activity are available upon request. 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 DCS services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DCS esta disponible a solicitud del cliente.

Statement of Certification by Employee/Applicant

By signing this form, I allow the Department of Child Safety to report final findings of any DCS child abuse investigation and the status of my Level 1 Fingerprint Clearance Card to the provider listed above. I attest under penalty of perjury, that the information provided is true, correct and complete to the best of my knowledge and belief. I further understand the provision of false information or intentional misrepresentation of information on this form may result in disciplinary action including termination.

A signed copy of this authorization must be placed in the personnel file.