ࡱ> QSNOPc ,bjbjQQ sP3f3fT0x& & kkkkk$P{&Dc!(!!!"nA#D#$1%3%3%3%3%3%3%$'p*W%ik#""##W%kk!!H%$$$#Fk!k!1%$#1%$$$!@E #$%%0&$4,$4,$4,k$##$#####W%W%$###&####4,#########& 1: Central Registry Clearance RequestCopy Photo ID Here or Attach a Separate PageMichigan Department of Health and Human ServicesSECTION 1 INFORMATION ON PERSON BEING CLEAREDName, (First, Middle, Last)Signature Required for Individual Being ClearedDate FORMTEXT       FORMTEXT       FORMTEXT      Also Known as Name (AKA)Social Security NumberDate of Birth FORMTEXT       FORMTEXT       FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      Phone NumberEmail FORMTEXT       FORMTEXT       FORMCHECKBOX  I am completing this for myself. FORMCHECKBOX  I would like to pick up my results in FORMTEXT      County (For Michigan Residents Only).SECTION 2 REQUESTER INFORMATIONCheck Appropriate Box FORMCHECKBOX  Employer FORMCHECKBOX  Volunteer Agency FORMCHECKBOX  Adoption/Foster Care Home Screening FORMCHECKBOX  Court/Law-Enforcement/Department of Corrections/Prosecuting Attorney FORMCHECKBOX  Other FORMTEXT      Name of Agency or OrganizationName of Requester FORMTEXT       FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      EmailFaxPhone Number FORMTEXT       FORMTEXT       FORMTEXT      Employers/Volunteer Agencies will ONLY receive responses of NO central registry if the person being cleared has approved this request with their signature. Employers/volunteer agencies will NOT receive notification if the name submitted has any central registry hits per CPL 722.627. For questions about completing this form, please contact the local Michigan Department of Health and Human Services, see attached contact list. This clearance does not identify individuals who may have child abuse/neglect history in other states, territories or tribal trust land. The confidentiality of central registry information is protected by Sections 7 through 7j of the Michigan Child Protection Law (MCL 722.627-722.627j). Anyone who violates this protection is guilty of a misdemeanor and is civilly liable for damages.The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. Instructions for filling out the DHS-1929Michigan Department of Health and Human ServicesMichigan residents requesting clearance on themselves (You must possess a Michigan identification) Complete section one and sign the form in the box provided. Include a copy of your Michigan picture identification (driver's license or passport are most acceptable). Please NOTE, the results will only be sent to the address on your picture identification. Submit your DHS-1929 form with identification to MDHHS for processing. See the attached list for MDHHS county office locations and contact numbers.Michigan agencies, schools, preschool. daycare providers, employers and volunteer agencies The person being cleared completes section one, signs the form and adds a copy of their picture identification (driver's license or passport are most acceptable). The requester completes section two with name of agency, name of requester, address, phone, email and fax number. Submit the DHS-1929 with identification to MDHHS for processing. See the attached list for MDHHS county office locations and contact numbers.Individuals outside of Michigan For out of state Individuals requesting clearance on themselves, complete section one and sign the form. Include a copy of your state picture identification (driver's license or passport are most acceptable). Please NOTE, the results will only be sent to the address on your picture identification. Submit your request to Michigan Department of Health and Human Services fax 517-763-0280.Agencies, schools, preschool. daycare providers, employers and volunteer agencies outside of Michigan For out of state agencies, the person being cleared completes section one, signs the form and adds a copy of their state picture identification (driver's license or passport are most acceptable). The requester completes section two with name of agency, name of requester, address, phone, email and fax number. Submit your request to Michigan Department of Health and Human Services fax 517-763-0280.Out-of-State Adoption and Foster Home Screening Please access our website at www.michigan.gov/MDHHS and follow the instructions for submitting an outstate request for adoption and foster home screening. For questions contact 517-284-9740.Michigan Camp Volunteers and Employees (All Types) Please contact the Department of Licensing and Regulatory Affairs, Bureau of Community Health Systems at 866-685-0006 or  HYPERLINK "http://www.michigan.gov/lara" www.michigan.gov/lara Submit completed form BCHS-camp 001 (Rev 1/16) to the address on the form.Outstate government agencies requesting information, please access our website at  HYPERLINK "http://www.michigan.gov/DHHS" www.michigan.gov/DHHS follow the links to child abuse and neglect or call 517-241-9794. If a person is listed on central registry the results will only be sent to the individual at the address on their photo identification. CountyAddressPhoneFaxAlcona2145 E. Huron Rd., East Tawas, MI 48730989-362-0300989-362-6629Alger413 Maple St., Munising, MI 49862906-387-4440906-387-4710Allegan3255 122nd., Ste. 300 Allegan, MI 49010269-673-7700269-673-7795Alpena711 W. Chisholm St., Alpena, MI 49707989-354-7200989-354-7242Antrim203 E. Cayuga St., PO Box 316, Bellaire, MI 49615231-533-8664231-533-8740Arenac3709 Deep River Rd., Standish, MI 48658989-846-5500989-846-4365Baraga108 Main St., PO Box 10, Baraga, MI 49908906-353-4700906-353-8415Barry430 Barfield Dr., Hastings, MI 49058269-948-3200269-948-410 IBay1399 W. Center Rd., Essexville, MI 48732989-895-2100989-895-2494Benzie448 Court Plaza Govt. Ctr., PO Box 114, Beulah, MI 49617231-882-1330231-882-9078Berrien401 Eighth St., PO Box 1407, Benton Harbor, MI 49023269-934-2000269-934-2115Branch388 Keith Wilhelm Dr., Coldwater, MI 49036517-279-4200517-278-5346Calhoun190 E. Michigan Ave., PO Box 490, Battle Creek, MI 49016269-966-1284269-966-2837Cass325 M-62, Cassopolis, MI 49031269-445-0200269-445-0298Charlevoix2229 Summit Park Dr., Petoskey, MI 49770231-348-1600231-347-6211Cheboygan827 S. Huron St., Cheboygan, MI 49721231-627-8500231-627-8546Chippewa463 East 3 Mile Rd., Sault Ste. Marie, MI 49783906-635-4100906-635-4173Clare725 Richard Dr., Harrison, MI 48625989-539-4260989-539-4200Clinton105 W. Tolles Rd., St. Johns, MI 48879989-224-5500989-224-3896Crawford230 Huron Grayling, MI 49738989-348-7691989-348-2838Delta305 Ludington St., Escanaba, MI 49829906-786-5394906-786-5350Dickinson1401 Carpenter Ave. Ste. A, Iron Mountain, MI 49801906-779-4100906-774-2775Eaton1050 Independence Blvd., Charlotte, MI 48813517-543-0860517-543-2125Emmet2229 Summit Park Dr., Petoskey, MI 49770231-348-1600231-347-6211Genesee125 E. Union St., P.O. Box 1628, Flint, MI 48501810-760-2550810-760-2745Gladwin675 E. Cedar Ave., Gladwin, MI 48624989-426-3300989-426-3353Gogebic301 E. Lead St., Bessemer, MI 49911906-663-6200906-663-6230Gd Traverse701 S. Elmwood Ste.19, Traverse City, MI 49684231-941-3900231-941-0037Gratiot201 Commerce Dr., Ithaca, MI 48847989-875-5181989-875-2811Hillsdale40 Care Dr., Hillsdale, MI 49242517-439-2200517-439-2272Houghton47420 State Hwy. M-26 Ste. 62, Houghton, MI 49931906-482-0500906-487-7726Huron1911 Sand Beach Rd., Bad Axe, MI 48413989-269-9201989-269-9875Ingham5303 S. Cedar St., Lansing, MI 48911517-887-9400517-887-9500Ionia920 E. Lincoln, Ionia, MI 48846616-527-5200616-527-1849Iosco2145 E. Huron Rd., East Tawas, MI 48730989-362-0300989-362-6629Iron337 Brady Ave., PO Box 250, Caspian, MI 49915906-265-9958906-265-6390Isabella1919 Parkland Dr., Mt. Pleasant, MI 48858989-772-8400989-772-8460Jackson301 E. Louis Glick Hwy., Jackson, MI 49201517-780-7400517-780-7160Kalamazoo322 E. Stockbridge Ave., Kalamazoo, MI 49001269-337-4900269-337-5179Kalkaska503 North Birch St., Kalkaska, MI 49646231-258-1200231-258-4482Kent121 Franklin St. SE Ste. 200, Grand Rapids, MI 49507616-248-1000616-248-1059Keweenaw3616 Highway US-41, PO Box 351, Mohawk, MI 49950906-337-3302906-337-1131Lake5653 S. M-37, Baldwin, MI 49304231-745-8159231-745-2930Lapeer1505 Suncrest Dr., Lapeer, MI 48446810-667-0800810-667-0795Leelanau701 S. Elmwood Ste. 19, Traverse City, MI 49684231-941-3900231-941-0037Lenawee1040 S. Winter St. Ste. 3013, Adrian, MI 49221517-264-6300517-264-6357Livingston2300 E. Grand River Ste. 1, Howell, MI 48843517-548-0200517-548-0298Luce500 W. McMillan, Newberry, MI 49868906-293-5144906-293-3857Mackinac199 Ferry Lane, Saint Ignace, MI 49781906-643-9550906-643-7467Macomb21885 Dunham Rd. Ste. 7, Clinton Township, MI 48036586-469-7700586-783-8136Macomb27690 Van Dyke Ave., Warren, MI 48093586-427-0600586-427-0668Macomb41227 Mound Rd. Ste. A, Sterling Heights, MI 48314586-254-1500586-254-8029Macomb19700 Hall Rd. Ste. A, Clinton Township, MI 48038586-412-6100586-412-6141Manistee1672 US 31 South, Manistee, MI 49660231-723-8375231-398-2106MarquetteCourthouse Annex, 234 W. Baraga Ave., Marquette, MI 49855906-228-9691906-228-3393Mason915 Diana St., Ludington, MI 49431231-845-7391231-843-1430Mecosta800 Water Tower Rd., Big Rapids, MI 49307231-796-4300231-796-0799Menominee2612 10th St., Menominee, MI 49858906-863-9965906-863-7426Midland1509 Washington Ste. A, Midland, MI 48641989-835-7040989-835-7597Missaukee10641 W. Watergate Rd., Cadillac, MI 49601231-779-4500231-779-4507Monroe903 S. Telegraph Ste. A, Monroe, MI 48161734-243-7200734-243-1660Montcalm609 N. State, PO Box 278, Stanton, MI 48888989-831-8400989-831-8496Montmorency13210 M-33, Atlanta, MI 49709989-785-4218989-785-2302Muskegon2700 Baker St., PO Box 4290, Muskegon Heights, MI 49444231-733-3700231-733-3872Newaygo1018 Newell, PO Box 640, White Cloud, MI 49349231-689-5500231-689-5586Oakland51111 Woodward Ave., Pontiac, MI 48342248-975-5400248-975-5550Oceana4081 W. Polk Rd., Hart, MI 49420231-873-7251231-873-3803Ogemaw444 E. Houghton Ave., West Branch, MI 48661989-345-5135989-345-4688Ontonagon408 Cooper St. Ste. B, Ontonagon, MI 49953906-884-4951906-884-6323Osceola800 Water Tower Rd., Big Rapids, MI 49307231-796-4300231-796-0799Oscoda200 W. Fifth St., Mio, MI 48647989-826-4000989-826-3961Otsego931 S. Otsego Ave., Gaylord, MI 49735989-732-1702989-732-8715Ottawa12185 James St. Ste. 200, Holland, MI 49424616-394-7200616-395-5526Presque Isle164 N. Fourth St., Rogers City, MI 49779989-734-2108989-734-2767Roscommon111 Union St., Roscommon, MI 48653989-275-5107989-275-5545Saginaw411 E. 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Main St., Centreville, MI 49032269-467-1200269-467-1229Sanilac515 S. Sandusky Rd., Sandusky, MI 48471810-648-4420810-648-4432Schoolcraft300 Walnut St. Rm. 175A, Manistique, MI 49854906-341-2114906-341-2110Shiawassee1720 E. Main St. Ste. 1, Owosso, MI 48867989-725-3200989-725-3308Tuscola1365 Cleaver Rd., Caro, MI 48723989-673-9100989-673-9209Van Buren57150 CR 681, Hartford, MI 49057269-621-2800269-621-2927Washtenaw22 Center St., Ypsilanti, MI 48198734-481-2000734-481-8386Wayne North13233 Hamilton Ave., Highland Park, MI 48203313-852-1700313-852-1891Wayne South1801 E. Canfield Detroit, MI 48207313-578-5500313-578-5392Wayne West27540 Michigan Ave., Inkster, MI 48141313-931-6400313-931-6439All WayneVisit www.michigan.gov/mdhhs for all officesWexford10641 W. Watergate Rd., Cadillac, MI 49601231-779-4500231-779-4507OutstatePO Box 30037, Ste. 510, Lansing, MI 48909-7537517-241-9794517-763-0280     DHS-1929 (Rev. 4-19) Previous edition obsolete.  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$3A JU( $3A J]( $3A Je( $3A Jm( $3A Ju( $3A J}( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $3A J( $-A J(- -'A J( --'A J( -   --- 42 "Name, (First, Middle, Last)        2   '--- .2 Signature Required for        /2 Individual Being Cleared          2 h  '--- 2 Date    2   '---- ---- ---- ---- ---- -- -- -- -- @1Courier New---  2 "   2 ,   2 6   2 ?   2 I   2 R  '---  2    2    2 )   2 2   2 <   2 E  '---  2    2    2    2    2    2   '-- -- -- -- --- /2 "Also Known as Name (AKA)         2   '--- ,2 Social Security Number       2   '--- 2  Date of Birth      2   '---- ---- ---- -- -- -- -- -- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  '---  2    2    2 )   2 2   2 <   2 E  '---  2    2    2    2    2    2   '-- -- -- -- --- 2 "Address    2 ]  'L--- 2 LCity   2 0L  'M--- 2 RMState     2 wM  '--- 2 Zip Code     2   '---- ---- ---- ---- -- -- -- -- -- -- (---  2 !"(   2 !,(   2 !6(   2 !?(   2 !I(   2 !R(  '(L---  2 !L(   2 !L(   2 !)L(   2 !2L(   2 !<L(   2 !EL(  '(M---  2 !`M(   2 !jM(   2 !sM(  '(---  2 !(   2 !(   2 !(   2 !(   2 !(   2 !(  '-- -- -- -- -- ;)--- 2 8" );Phone Number       2 8);  ';)--- 2 8);Email   2 8=);  '---- ---- ---- ---- -- -- -- -- P;---  2 I";P   2 I,;P   2 I6;P   2 I?;P   2 II;P   2 IR;P  'P;---  2 I;P   2 I;P   2 I);P   2 I2;P   2 I<;P   2 IE;P  '-- -- -- hQ--- hQ hQ '--c2T#-- '---  2 b4Qh  ;2 b8 QhI am completing this for myself.         2 bQh  'h7Q--- h7Q h7Q '--c4T%-- '---  2 b6Q7h  C2 b:%Q7hI would like to pick up my results in          2 b0Q7h  'hQ7---  2 `<7Qh   2 `F7Qh   2 `P7Qh   2 `Y7Qh   2 `c7Qh   2 `l7Qh  'hQ--- C2 b%QhCounty (For Michigan Residents Only).         2 bQh  '---- ---- ---- ---- ---- -- --    -- i--- 2 ziSECTION   .2 zji2 REQUESTER INFORMATION      2 zPi  '---- ---- ---- ---- ---- ----   --- +2 "Check Appropriate Box         2   '---- ---- -- -- -- ---   '--2#-- '---  2 4  2 8Employer     2 z  'V--- V V '---- '---  2 V  #2 VVolunteer Agency     2 5V  'V--- V V '--l]-- '---  2 nV  #2 rVAdoption/Foster     (2 VCare Home Screening        2 V  '---   '---- '---  2   2  Court/Law    2 - 22  Enforcement/Department of        ;2  Corrections/Prosecuting Attorney            2   '-- -- j--- j j '--2#-- '---  2 4j  2 8jOther    2 ^j  'j---  2 oj   2 yj   2 j   2 j   2 j   2 j  '-- -- --- 82 "Name of Agency or Organization          2   '--- %2 Name of Requester       2   '---- ---- ---- ---- -- -- -- -- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  '---  2    2    2 )   2 2   2 <   2 E  '-- -- -- --- 2 "Address    2 ]  'L--- 2 LCity   2 0L  'M--- 2 RMState     2 wM  '--- 2 Zip Code     2   '---- ---- ---- ---- -- -- -- -- -- --  ---  2 "    2 ,    2 6    2 ?    2 I    2 R   ' L---  2 L    2 L    2 )L    2 2L    2 <L    2 EL   ' M---  2 `M    2 jM    2 sM   ' ---  2     2     2     2     2     2    '-- -- -- -- --   --- 2 "  Email   2 J    ' L --- 2  L Fax   2 / L   '  M--- 2 R M  Phone Number       2 M    '---- ---- ---- ---- -- -- -- -- -- 4 ---  2 ." 4   2 ., 4   2 .6 4   2 .? 4   2 .I 4   2 .R 4  '4L ---  2 . L4   2 . L4   2 .) L4   2 .2 L4   2 .< L4   2 .E L4  '4 M---  2 .RM 4   2 .\M 4   2 .fM 4   2 .oM 4   2 .yM 4   2 .M 4  '-- -- -- -- 5--------------- 52 D"5Employers/Volunteer Agencies         ---  2 D5   2 D5will ONLY rece     2 D|[5ive responses of NO central registry if the person being cleared has approved this request                         2 W"}5with their signature. Employers/volunteer agencies will NOT receive notification if the name submitted has any central regist                               #2 W5ry hits per CPL     /2 i"5722.627. For questions a        2 ij5bout completing this form, please contact the local Michigan Department of Health and Human Services, see                             ,2 |"5attached contact list.       2 |5   2 "}5This clearance does not identify individuals who may have child abuse/neglect history in other states, territories or tribal                               2 r5tr 2 { 5ust land.    2 5   2 "}5The confidentiality of central registry information is protected by Sections 7 through 7j of the Michigan Child Protection La                                    2 z5w (MCL 722.627      2 5-  2 "j5722.627j). Anyone who violates this protection is guilty of a misdemeanor and is civilly liable for damage                           2 5s.  2  5  '---- ---- ---- -- -- -- --- 2 "}The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of                                    2   2 race,     2 "hreligion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual                            M2 ,orientation, gender identity or expression,              ;2 " political beliefs or disability.         2   '---- -- -- ------ -- ----  "SystemxIL f?F"--00  //.. Ս ՜.+,D՜.+,< hp  4Michigan Department of Health and Human ServicesW<0 #Central Registry Clearance Request Title, 8@ _PID_HLINKSA EX]http://www.michigan.gov/DHHSWCZhttp://www.michigan.gov/lara  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEGHIJKLMRRoot Entry F`0E TData g1Table4,WordDocumentsPSummaryInformation(DocumentSummaryInformation8FCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q