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 |
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Check All That Apply |
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Mailing Address |
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Child Placing Agency |
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Residential Child Care Facility |
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Child Day / Night Care Center |
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Telephone Number ( |
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Email: |
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Family Day / Night Care Home |
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PRINT Requestor’s Name |
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Exempt Child Day Care Center |
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Requestor |
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Date |
Medicaid Rehab. Provider |
Signature |
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DHR Vendor |
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Witness |
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Date |
Other (Please Specify) |
Signature |
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_________________________________ |
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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 |
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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.
_________________________________ |
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_________________________________ |
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Signature |
Date |
Signature of Witness |
Date |
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. |
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Request Denied |
______________________________________________________________________________ |
Other _________________________________________________________________________________________ |
_________________________________________________________ |
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Office of Child Protective Services |
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Date Completed |
DHR-FCS-1598 (Revised December 2009)