DSS Form 3072.pdf

DSS Form 3072 (APR 24)

REQUEST FOR CENTRAL REGISTRY AND/OR CHILD ABUSE RECORD CHECK

Online Portal is available at: https://providerportal@dss.sc.gov

Utilize DSS Forms 2924 or 37201 for all Child Care Requests

I. Purpose for Request (check all that apply) 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:

Becoming or remaining a foster parent or potential adoptive parent Adults over the age of 18 residing in a potential foster home or adoptive home Becoming an employee or volunteer for Richland County CASA Becoming an employee or volunteer for the S.C. Department. of Children's Advocacy to include: Continuum of Care; Foster Care Review Board and/or SC Guardian ad Litem Program Group Home (emergency shelters, wilderness camps, Child Caring Institution)

B. I am requesting a search of the Central Registry of Child Abuse and Neglect ONLY in connection with:

Becoming or remaining an employee or volunteer for Adult Care Other: Please specify ____________________________________________

II. Please check appropriate fee box and include payment (Check or Money Order ONLY) Only one category applies!

Non -Profit Entities (CASA, etc.) $ 8.00 Name Change $ 8.00 For Profit Entities $ 25.00 Foster Care/Adoption $ 8.00 State Agencies $ 8.00 Private Adoptions Investigations $25.00 Schools $ 8.00 Adult Care Facility $ 8.00 Group Home Facilities $ 25.00 Other (individual request, etc.) $ 8.00

III. Please print or type the entire name of person to be searched. Incomplete or illegible forms will not be processed.

Full Name (No Initials): ___________________________________ First, Middle Last

DOB: _____________ Gender:___________ Race: ___________

Maiden/Former Name/Aliases: __________________________________ Complete SSN (No X’s): ________________________________ Place of Birth: _______________________________________________ Current Address: _____________________________________________ Previous Address(es): __________________________________

IV. Mail Results to:

Name: ___________________________________________________ ATTN:

Address: ___________________________________________________ Tel. No. ___________________________________

City/State/Zip: _______________________________________________ Email: ___________________________________

V. I do hereby authorize the South Carolina Department of Social Services (SCDSS) to research its records 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 above. I understand that the information provided may prove to be unfavorable to me. I agree to hold SCDSS and its staff harmless from liability associated with the 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.

Please mail appropriate payment (check or money order only) payable to: Department of Social Services (DSS) and form for processing to: South Carolina Dept. of Social Services, ATTN: Cashier, 1535 Confederate Avenue, PO Box 1520, Columbia, SC 29202-1520.

Your signature MUST be witnessed or notarized.

Signature of Applicant Date

Signature of Witness Date

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

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

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.

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

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

Authorized DSS Employee Date https://providerportal@dss.sc.go

DSS Form 3072 (APR 24)

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 in the appropriate box.

SECTION II: Central Registry Fee: Please check appropriate fee box.

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

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

• Maiden/Former Name/Aliases: List the name(s).

• Date of Birth: Month/Day/Year

• Gender: (Self Explanatory)

• Race: (Self Explanatory)

• Social Security Number: All the information requested on this form is necessary to conduct a thorough search. Your SSN will be used only to conduct what we hope will be a thorough central registry/database check and will not be given to any person other 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 IV: 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, telephone number, and email.

SECTION V: Mail payment payable to Department of Social Services (DSS); 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) 898-7318 EXTENSION 4, 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 Child Welfare Services.

DSS personnel in the Division of Child Welfare 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.

3. Sign and date form; Results are returned via online portal or envelope is stamp, “confidential” and mail to return address.

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