DCF Contractors All SECURITY CLEARANCE.pdf

COLLECT Check Request

Revised 06/15/18

Applicant’s Name: __________________ _________________ __________ Last First Middle Initial

Maiden Name (if applicable): ______________________

Alias Name(s) (if applicable): _ ________________________

Applicant’s Date of Birth: ____ Month Day Year

Applicant’s Social Security No.: _______________________

Applicant’s Height: ____ft ___in

Applicant’s Weight: ____lbs

Color of Hair: __ ____

Color of Eyes: __ ______

Requester: ____________________ Location:_______________ Date: __________

Program: Circle one

Employment

Intern (Paid)

Intern (Unpaid)

Volunteers – Paid or Unpaid

Student Shadowing

Contractor

Operator: ____________________________________

BACKGROUND INFORMATION SHEET

Employee Contractor Intern Volunteer Other

Name:________________________________________________________________________ Last Name First Name Middle Name (spell out)

Maiden Name (if applicable):______________________________________________________

Have you ever been known by another name (include aliases, legal name changes, etc.)

YES NO If yes, list the name and the reason below:

Classification/Job Title:___________________________ Work Location:___________________

Email:_________________________________________________________________________

Home Address:_________________________________________________________________ Street City/Town State Zip

Previous Address:_______________________________________________________________ Street City/Town State Zip

Date of Birth:____/____/____ Place of Birth:______________________________________ MM DD YY City/Town State

Social Security Number:_______/____/_______ Sex: M F Citizenship: Y N

Race:__________ Height:__________ Weight:__________ Hair:__________ Eyes:__________

Do you have a valid driver’s license? Yes No Operator Number:_____________________

State Issued:______ Has your license ever been REVOKED or SUSPENDED? Yes No

If Yes, please indicate whether REVOKED or SUSPENDED and state reason:

If REINSTATED, list date of reinstatement:___________________________________________

OVER

TMartelly Typewritten Text

TMartelly Typewritten Text

TMartelly Typewritten Text

HAVE YOU EVER BEEN CONVICTED FOR AN OFFENSE AGAINST CRIMINAL OR MILITARY

LAW, FORFEITED BOND, AND/OR ARE THE CRIMINAL CHARGES CURRENTLY PENDING

AGAINST YOU? YES NO

Special Note: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes § 46-b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statues, you may swear under oath that you have never been arrested. Criminal records that may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. § 46b- 146), an adjudication as a youthful offender (C.G.S. § 54-76o), a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found guilty or a conviction for which the person received an absolute pardon (C.G.S. § 54-142a).

IMPORTANT QUALIFICATION: If you have a charge which has been resolved without a conviction, it must be disclosed herein if the matter has not gone to final disposition and your record has not been expunged. Examples include, but are not limited to, a “nolle” (which remains pending for 13 months) and accelerated rehabilitation (which remains pending until all court imposed conditions have been satisfied and the matter is formally dismissed by a judge). It is your responsibility to ensure that any charges not disclosed herein have, in fact, been erased from your criminal history record.

If YES, please attach a detailed explanation of the circumstances

DATE PLACE COURT LOCATION OFFENSE(S) DISPOSITION

The information I have given above is true, accurate and complete to the best of my knowledge. I understand any false, inaccurate, misleading or incomplete answer may result in a rescinded offer of employment or disciplinary action including termination from State service.

Signature of applicant/employee Date signed

Signature of volunteer/intern Date signed

NOTE: Fingerprints taken by the Department of Children and Families will be submitted to the Connecticut State Police and the FBI for a criminal history check.

Form DCFBIS New 02/02 Revised 06/08/18

BACKGROUND INFORMATION SHEET

Supplemental Information

Name:____________________________

Connecticut Department of Children and Families AUTHORIZATION FOR DCF CPS BACKGROUND CHECK (Central Registry Only)

DCF-3031

7/2022 (Rev.) Page 1 of 1

I, (Applicant Name): _______________________________________________ do hereby authorize the Department of Children and Families to research its records and if applicable request out of state checks, to determine whether or not I am on the central registry of persons responsible for child abuse and neglect. I understand that this information may be used to determine my suitability for (check one):

☐Employment ☐ Day Care ☐ Volunteer ☐ Intern ☐ Mentor ☐ Other

I release the Department of Children and Families from any liability for any damages I may incur because of the release/use of this information.

Name of Agency (requesting background check) Attention:

Address: (No. and Street): City: State: Zip:

I submit the following information to assist the Department of Chidlren and Families in their search.

Applicant Last Name: Applicant First Name: Middle: DOB:

Applicant Address: (No. and Street): Apt. # City: State: Zip: Start date at current address: (mm/dd/yyyy)

List all previous applicant addresses for the last five years Check if an additional sheet is necessary, and attached Address (No. and Street): Apt. # City: State: Zip: Dates From:

(mm/dd/yyyy) To

(mm/dd/yyyy)

Other names I have used (including preferred names, maiden, and previous marriages) Check if an additional sheet is necessary, and attached

Last Name: First Name: Middle Name:

Names of ALL children - biological/step (Including adult children in or out of the home) Check if an additional sheet is necessary, and attached

Last Name: First Name: Middle: DOB: Gender:

Female Male Other

Female Male Other

Female Male Other

This authorization will expire 180 days after the date of the signature

Applicant Signature: Date:

Submit at https://portal.dcf.ct.gov/Portal/Main/#dashboard. To enroll your agency in the portal, please contact bgc.verification@ct.gov.

For questions or support, please contact the Background Check Unit at bgc.verification@ct.gov.

Connecticut Department of Children and Families

CONFIDENTIALITY AGREEMENT

DCF-2118

8/19 (Rev.) Page 1 of 1

I (Enter FIRST name). (Enter LAST name).

understand that I am being granted access to confidential child protection information that is the property of the State of Connecticut Department of Children and Families (DCF). I am a/an:

Employee Intern Consultant Employee of the following DCF Service Provider:

Other authorized user:

By signing this document , I understand and agree as follows:

1. In the course of providing services to and/or performing my duties for DCF, I may have access to hard copy and or electronic confidential DCF case information. “Confidential information” pertains to that information currently under the protection of state and federal confidentiality statutes pertaining to the business of this agency, specifically child welfare data and protected health information.

Confidential Information encompasses written, verbal or electronic form.

2. I will not solicit confidential information from any source beyond what is necessary to perform my duties.

3. I will not discuss confidential information in any setting or forum except when performing duties directly related to my duties.

4. I will not discuss confidential information with any person who is not employed by DCF, unless specifically authorized to do so by DCF for purposed of performing my duties.

5. I will only discuss confidential information with authorized persons in an area where privacy can be ensured. For example, confidential information will not be discussed in public or semi-public area including hallways, waiting rooms, elevators and restaurants.

6. I will not distribute confidential information in any written or documentary or electronic format to anyone who is not employed by DCF unless specifically authorized to do so by DCF for purposes of performing my duties. This specifically includes, but is not limited to, use of DCF information in a research project or written publication.

7. If I recognize the name of a DCF adult or child client with whom I have a personal or business relationship not connected with my duties at DCF, I will immediately notify my DCF Supervisor and will not read additional information or access the case further without written DCF approval.

8. I will not remove any confidential information, either physically or electronically, from my workspace, including assigned equipment or electronic media, operated by the Department of Children and Families, unless expressly authorized in writing by DCF.

9. I will return all confidential information in my possession to DCF upon the completion of my duties, and I will not keep any copies of any information, in any formation, to which I have gained access.

10. I understand that Connecticut General Statutes §17a-28 addresses the confidentiality of DCF case records and states in part:

“…The information contained in reports and any information relative to child abuse0 wherever located, shall be confidential”

“ …Any violation of this section…shall be punishable by a fine of not more than one thousand dollars or imprisonment for not more than one year.”

11. I understand that I may be subject to the above-cited criminal penalty if I illegally disclose confidential DCF information.

12. I understand that I may also be subject to a civil lawsuit if I illegally disclose confidential information.

13. I understand that if I am sued for a willful or negligent breach of confidentiality, DCF, at its option, may not be responsible for any costs or damages associated with said suit.

14. I understand that my access privileges to confidential information will expire twelve (12) months from the date I sign this Agreement unless an authorized DCF manger requests that my access requests that my access privileges be renewed for another twelve (12) months. If my access is renewed, the provisions of this Agreement will remain in full force and effect even if I am not asked to sign a new Confidential Agreement.

15. I understand that even after my access privileges expire, and even after I am, no longer providing services for DCF, the provisions of this Confidentiality Agreement remain in full force and effect indefinitely, including my potential civil and criminal liability for breach of confidentiality.

Name of Person Being Granted Access: Signature of Person Being Granted Access: Date:

Name of Witness: Signature of Witness: Date:

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

Division of State Police

NCPA/VCA Waiver and Consent Form for Governmental Qualified Entities-DCF 10/17/2018

National Child Protection Act/Volunteers for Children Act Waiver and Consent Form for

Department of Children and Families

The criminal history record checks performed under the National Child Protection Act (NCPA), as amended by the Volunteers for Children Act (VCA), will determine if you, as a care provider (current or prospective employee, volunteer, contractor/vendor, or owner/operator), have been convicted of crimes that bear upon your fitness to be responsible for the safety and well-being of children (persons less than 18 years old), the elderly (persons 60 years of age or older), or individuals with disabilities (persons with a mental or physical impairment who require assistance to perform one or more daily living tasks).

Pursuant to the NCPA/VCA, this form must be completed and signed by every current or prospective provider for whom criminal history records are requested by a Governmental Qualified Entity (QE) or Department of Children and Families (DCF) Office. QEs/DCF provides care, treatment, education, training, instruction, supervision, recreation, care placement services, or licenses/certifies others who provide care to, vulnerable populations (children, the elderly, or individuals with disabilities).

Requesting QE/DCF Information:

QE/DCF Name Department of Children and Families QE/DCF Address 505 Hudson Street, Hartford, CT. 06106 QE/DCF Telephone Number 860-723-7292

I am a current or prospective (check one): ___ Employee ___ Volunteer ___ Contractor/Vendor ___ Owner/Operator ___ Foster Care Applicant ___ Adoption Applicant

I have been convicted of or pled guilty to a crime. ___ No ____ Yes*

*If yes, please provide a description of the crime and the particulars of the conviction on the back of this waiver.

I hereby authorize the requesting QE/DCF to submit a set of my fingerprints to the Connecticut State Police Bureau of Identification (SPBI) and Federal Bureau of Investigation (FBI) for the purpose of accessing and reviewing state and national criminal history records that may pertain to me. I further understand the following:

• My fingerprints will be used to check the criminal history records of the SPBI and the FBI;

• I can receive a state criminal history record from the SPBI and a national criminal history record from the FBI pursuant to Title 28, Code of Federal Regulations, §16.30-16.34;

• I am entitled to challenge the accuracy and completeness of any information contained in such records;

• The QE/DCF may choose to deny me unsupervised access to persons to whom the QE/DCF provides care until the criminal history record check is completed; and

• I may obtain a prompt determination as to the validity of my challenge before a final decision is made.

By signing this Waiver, it is my intent to authorize the dissemination of any state or national criminal history record which may pertain to me, to the requesting QE/DCF. I have read and understood the foregoing and the information provided is true and accurate to the best of my knowledge and belief.

*Printed Name:_________________________________ Signature:___________________________________________

*Date of Birth:______________________ *Address:______________________________________________________ *as it appears on a valid identification document issued by a governmental agency

NOTE: The original waiver must be retained by the QE/DCF in the provider’s case file.

Noncriminal Justice Applicant’s Privacy Rights

Updated 11/6/2019

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing.1 These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12, among other authorities.

You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later), by the agency that will receive your criminal history results, when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared, or retained. 2

You must be advised in writing of the procedures for obtaining a change, correction, or update of your FBI criminal history record as set forth at 28 CFR 16.34.

You must be provided the opportunity to complete or challenge the accuracy of the information in your FBI criminal history record (if you have such a record).

If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the FBI criminal history record.

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks and https://www.edo.cjis.gov.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI by submitting a request via https://www.edo.cjis.gov. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.)

You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy

Compact Council.3

If you need additional information or assistance, please contact:

Applicant Signature:_______________________________ Date:__________________________________

1 Written notification includes electronic notification, but excludes oral notification.

2 See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

Connecticut Records:

Department of Emergency Services and Public Protection

State Police Bureau of Identification (SPBI)

1111 Country Club Road

Middletown, CT 06457

860-685-8480

Out-of-State Records:

Agency of Record

OR

FBI CJIS Division-Summary Request

1000 Custer Hollow Road

Clarksburg, West Virginia 26306 https://www.fbi.gov/services/cjis/identity-history-summary-checks https://www.edo.cjis.gov/ https://www.edo.cjis.gov/ https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

Agency Privacy Requirements for Noncriminal Justice Applicants

Updated 11/06/2019

Authorized governmental and non-governmental agencies/officials that conduct a national fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose (such as employment or a license, immigration or naturalization matter, security clearance, or adoption) are obligated to ensure the applicant is provided certain notices and that the results of the check are handled in a manner that protects the applicant’s privacy. All notices must be provided in writing.1 These obligations are pursuant to the Privacy Act of 1974, Title

5, United States Code (U.S.C.), Section 552a, and Title 28, Code of Federal Regulations (CFR), Section 50.12, among other authorities.

Officials must ensure that each applicant receives an adequate written FBI Privacy Act Statement (dated

2013 or later) when the applicant submits his/her fingerprints and associated personal information.2

Officials must advise all applicants in writing that procedures for obtaining a change, correction, or update of an FBI criminal history record are set forth at 28 CFR 16.34. Information regarding this process may be found at https://www.fbi.gov/services/cjis/identity-history-summary-checks and https://www.edo.cjis.gov.

Officials must provide the applicant the opportunity to complete or challenge the accuracy of the information in the FBI criminal history record.

Officials should not deny the employment, license, or other benefit based on information in the FBI criminal history record until the applicant has been afforded a reasonable time to correct or complete the record or has declined to do so.

Officials must use the FBI criminal history record for authorized purposes only and cannot retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.3

The FBI has no objection to officials providing a copy of the applicant’s FBI criminal history record to the applicant for review and possible challenge when the record was obtained based on positive fingerprint identification. If agency policy permits, this courtesy will save the applicant the time and additional FBI fee to obtain his/her record directly from the FBI by following the procedures found at 28 CFR 16.30 through 16.34. It will also allow the officials to make a more timely determination of the applicant’s suitability.

Each agency should establish and document the process/procedures it utilizes for how/when it gives the applicant the FBI Privacy Act Statement, the 28 CFR 50.12 notice, and the opportunity to correct his/her record. Such documentation will assist State and/or FBI auditors during periodic compliance reviews on use of FBI criminal history records for noncriminal justice purposes.

If you need additional information or assistance, contact:

1 Written notification includes electronic notification, but excludes oral notification.

2 See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3 See 5 U.S.C. 552a (b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d), 50.12(b) and 906.2(d).

Connecticut Records:

Department of Emergency Services and Public Protection

State Police Bureau of Identification (SPBI)

1111 Country Club Road

Middletown, CT 06457

860-685-8480

Out-of-State Records:

Agency of Record

OR

FBI CJIS Division-Summary Request

1000 Custer Hollow Road

Clarksburg, West Virginia 26306 https://www.fbi.gov/services/cjis/identity-history-summary-checks https://www.edo.cjis.gov/ https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

FBI Privacy Act Statement

This privacy act statement is located on the back of the FD-258 fingerprint card.

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential

Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s

Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in

NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the

Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

As of 03/30/2018

Applicant Signature:_______________________________ Date:__________________________________

STATE OF CONNECTICUT

www.ct.gov/dcf

An Equal Opportunity Employer

DEPARTMENT of CHILDREN and FAMILIES

Making a Difference for Children, Families and Communities

Vannessa L. Dorantes Commissioner Designate

Ned Lamont Governor

ACKNOWLEGEMENT OF RECEIPT

PRIVACY REQUIREMENTS FOR NONCRIMINAL JUSTICE APPLICANTS

I,__________________________________________, have received a copy of the Privacy Requirements of Noncriminal Justice Applicants and the Federal

Bureau of Investigation Privacy Act Statement.

Print Name

Signature Date

Employee