The Alabama Central Registry Clearance form is a document used to request a background check related to child abuse or neglect. This form is essential for individuals or organizations that provide unsupervised care for children, ensuring that they are not listed in the state's Central Registry for child abuse or neglect. Completing this form accurately is crucial for the safety and well-being of children in care settings.
The Alabama Central Registry Clearance form plays a crucial role in ensuring the safety and well-being of children in various care settings. Designed for individuals and organizations that provide unsupervised care, this form is essential for anyone seeking to work or volunteer in environments such as child placing agencies, residential child care facilities, and day care centers. By collecting detailed information about the individual being cleared—including their name, date of birth, and any aliases—the form facilitates a thorough background check. The Alabama Department of Human Resources utilizes this information to search the Child Abuse/Neglect Central Registry, determining whether the individual has been implicated in any cases of child abuse or neglect. Additionally, the form requires the individual to authorize the release of their information, waiving any rights to review or contest the findings. This process not only helps protect vulnerable children but also supports organizations in making informed hiring decisions. Understanding the significance and requirements of this form is vital for anyone involved in child care services in Alabama.
ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD ABUSE / NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE
PRINT OR TYPE in black or blue ink. Additional information regarding the CA/N Central Registry is on the back of this form.
** See instructions for the address to use when submitting this form. **
Requesting Person or Agency/Organization
Check All That Apply
Mailing Address
Child Placing Agency
Residential Child Care Facility
Child Day / Night Care Center
Telephone Number (
)
Email:
Family Day / Night Care Home
PRINT Requestor’s Name
Exempt Child Day Care Center
Requestor
Date
Medicaid Rehab. Provider
Signature
DHR Vendor
Witness
Other (Please Specify)
_________________________________
The person whose name and identifying information, printed or typed below, will provide unsupervised care and
supervision of children as an
employee
volunteer
other. This person’s specific job/role is or will be:
_________________________________________________________________________________________________
Name _____________________________________________ Sex
Last First Middle
Male
Race ___________ DOB ___/___/______
Female
Current Mailing Address
__________________________________________________________________________
Alias, Maiden & Prior Married Name(s)
______________________________________________________________
Name & DOB of Spouse & Former Spouse(s)
_________________________________________________________
Name & DOB of Children / Stepchildren
Alabama counties where person has lived and/or worked
_________________________________________________
Attach additional pages as needed to provide all information requested above.
To be completed by person being cleared
I authorize the Alabama Department of Human Resources to release information contained in the Child Abuse / Neglect Central Registry about me to the above named person/agency/organization. I hereby waive any right to any review or hearing to which I may otherwise be entitled. I further release the Department of Human Resources, its officers, and employees from any and all claims arising out of or in any way connected to the release or dissemination of any information concerning me.
________________
Signature of Witness
To be completed by DHR
A search of the Alabama Child Abuse / Neglect Central Registry has been completed with the information provided to determine if the person identified above has been named as being responsible for child abuse or neglect in Alabama. DHR releases only that information which is necessary to discover or prevent child abuse / neglect.
Substantiated report (i.e., indicated) located. See attached information.
Type Report:
Physical Abuse
Neglect
Sexual Abuse
Mental Abuse / Neglect
No report located.
Request Denied
______________________________________________________________________________
Other _________________________________________________________________________________________
______________________________________
Office of Child Protective Services
Date Completed
DHR-FCS-1598 (Revised December 2009)
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