ࡱ> c !bjbj ;<KbKbXD :::::NNN8D,NW.L***^L,=W?W?W?W?W?W?W$Y\cW:^^cW::**4xWF:*:*=W=W=RlU* ߛvS*)WW0WS"N]k|N]TUUN]: V ZH@4cWcWWN] B : CENTRAL REGISTRY CHECK FOR THE FOLLOWING TYPES OF EMPLOYMENT OR VOLUNTEERISM, STATE LAW OR KENTUCKY ADMINISTRATIVE REGULATION AUTHORIZES A CHILD ABUSE/NEGLECT (CA/N) CHECK AS A CONDITION OF EMPLOYMENT OR VOLUNTEERISM (www.lrc.ky.gov). PLEASE CHECK THE CATEGORY LISTED BELOW THAT APPLIES TO YOU FOR WHICH THE CHILD ABUSE OR NEGLECT CHECK IS BEING REQUESTED:  FORMCHECKBOX  Child-Placing Agency (Foster/Adoption/Independent Living) Employee or Volunteer (Required by 922 KAR 1:310)  FORMCHECKBOX  Residential Child-Caring Facility Employee or Volunteer (Required by 922 KAR 1:300) (Institution/Group Home/Emergency)  FORMCHECKBOX  Public School Employee, Student Teacher, Contractor, or School-Based Decision-Making Council Member (Required by KRS 160.380)  FORMCHECKBOX  Private, Parochial, or Church School Employee or Student Teacher (Permitted by KRS 160.151)  FORMCHECKBOX  Youth Camp Employee, Contractor, or Volunteer (Required by KRS 194A.380-194A.383)  FORMCHECKBOX  Power of Attorney Regarding the Care and Custody of a Child (Required by KRS 403.352)  FORMCHECKBOX  Supports for Community Living (SCL) Employee (Required by 907 KAR 12:010)  FORMCHECKBOX  Michelle P. Waiver (Required by 907 KAR 1:835)  FORMCHECKBOX  Home and Community Based (HCB) Waiver (Required by 907 KAR 1:160 and 7:010)  FORMCHECKBOX  Acquired Brain Injury Waiver Services (Required by 907 KAR 3:090)  FORMCHECKBOX  Childrens Advocacy Center (Required by 922 KAR 1:580)  FORMCHECKBOX  Court Appointed Special Advocate (CASA) (Required by KRS 620.515)  FORMCHECKBOX  Personal Care Attendant (Required by 910 KAR 1:090) Other (If none of the above categories is applicable, please explain the reason for requesting a child abuse or neglect check, including the statutory or regulatory authority for the request): _______________________________________________________________________________________ PERSONAL INFORMATION REGARDING THE INDIVIDUAL SUBMITTING TO A CHILD ABUSE OR NEGLECT CHECK (Please print and submit identifying information such as a copy of your drivers license, social security card, or birth certificate): NAME: ______________________________________________________________________________________ (first) (middle) (maiden/nickname/other) (last) Sex: ___ Race: _________ Date of Birth: _______________ Social Security/Individual Taxpayer Identification #:__________________________ Date of Initial Hire: _______________________ Present Address: _______________________________________________________________________________ City State Zip Code Previous Address: _____________________________________________________________________________ City State Zip Code Previous Address: _____________________________________________________________________________ City State Zip Code Previous Address: _____________________________________________________________________________ City State Zip Code Previous Address: _____________________________________________________________________________ City State Zip Code Please list your addresses for the last five years. Use another sheet of paper, if necessary. A credit or debit card payment in the amount of ten dollars ($10.00) must accompany your request to process a Child Abuse or Neglect Check. The Child Abuse or Neglect Check will NOT be processed without payment. I hereby authorize the Cabinet for Health and Family Services to complete a Child Abuse or Neglect check and to submit the results of the check to me and, on my behalf, to the employer or agency listed below. I also release the Cabinet for Health and Family Services, its officers, agents, and employees, from any liability or damages resulting from the release of this information. All the information provided is complete and true to the best of my knowledge. I understand if I give false information or do not report all of the information needed, I may be subject to prosecution for fraud. _________ Signature of the Individual Submitting to the Child Abuse or Neglect Check Date The individual authorizing a Child Abuse or Neglect check may submit a CHFS-305, Authorization for Disclosure of Protected Information, authorizing the Cabinet for Health and Family Services to disclose additional information regarding a finding to the employer or agency listed below should the employer or agency request additional information pursuant to 922 KAR 1:510, Authorization for disclosure of protection and permanency records. In addition to receiving the results myself, I authorize the Cabinet for Health and Family Services to share the results with the following employer or agency: NAME OF EMPLOYER/AGENCY: _______________________________________________________ ADDRESS: ______ CITY: ___ STATE: _______________ ZIP: PHONE: _______________ E-MAIL ADDRESS: ____________________________________________ RESULTS OF CHILD ABUSE OR NEGLECT CHECK [FOR OFFICIAL USE ONLY]  FORMCHECKBOX  No reportable incident found in accordance with 922 KAR 1:470  FORMCHECKBOX  Substantiated child abuse found on the registry Date of substantiated finding: ____________  FORMCHECKBOX  Substantiated child neglect found on the registry Date of substantiated finding: ____________ The substantiated abuse or neglect finding relates to sexual abuse, sexual exploitation, a child fatality, near fatality, or involuntary termination of parental rights  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  A matter subject to administrative review found in accordance with 922 KAR 1:470 CHECK CONDUCTED ON _________________BY ____________________________________________     CENTRAL REGISTRY CHECK DPP-156 (R. 8/2019) 922 KAR 1:470 Page  PAGE 2 of  NUMPAGES 2 DPP-156 COMMONWEALTH OF KENTUCKY (R. 8/2019) CABINET FOR HEALTH AND FAMILY SERVICES 922 KAR 1:470 Department for Community Based Services KentuckyUnbridledSpirit.com An Equal Opportunity Employer M/F/D  Page  PAGE 1 of  NUMPAGES 2 g h v w x / 0 > ? @   عxfT#jh*<hCCJUaJ#j\h*<hCCJUaJ#jh*<hCCJUaJ#jth*<hCCJUaJ#jh*<hCCJUaJh*<hCCJaJjh*<hCCJUaJhJ{hC5CJOJQJaJh*<hC5CJOJQJaJ h hCh>kMhC5\ hC5\ g i /  0 4 $h]ha$gdC$ Bh1$]ha$gdC$ 4h1$]ha$gdC $h1$]ha$gdC $h]ha$gdC$a$gdC$a$gdC & ' ( 0 1 ? @ A 45CDEzh#jh*<hCCJUaJ#jh*<hCCJUaJ#jh*<hCCJUaJ#jh*<hCCJUaJ#j,h*<hCCJUaJ#jh*<hCCJUaJjh*<hCCJUaJ#jDh*<hCCJUaJh*<hCCJaJ$\/@p%2;R09P.0ǻppppah*<hCCJOJQJaJh*<hCB*CJaJphh9hC5CJaJh9hCCJaJh*<hCCJaJh*<hCB*CJaJphh*<hCCJaJh*<hC5CJaJh*<hC>*CJaJh*<hCCJaJjh*<hCCJUaJ#jph*<hCCJUaJ!/%TRP./]^ $h]ha$gdC$a$gdCgdC hdh]hgdC$hdh]ha$gdC $h]ha$gdC0F]u=";<t}&'23ûyf%jh*<hCCJOJQJUaJh*<hC>*CJOJQJaJhCh9hC5h*<hC5>* hC5h*<hC5h*<hC\ h*<hCh*<hC>*h*<hCCJOJQJaJh*<hC>*CJOJQJaJh*<hCCJOJQJaJh9hCCJOJQJaJ'^u"#t234s-$h$d%d&d'dNOPQ]ha$gdC$hdh]ha$gdC hdh]hgdCh]hgdC-$h$d%d&d'dNOPQ]ha$gdC $h]ha$gdC 4PXZ[]^`xxxxsqqqqqgdC-$h$d%d&d'dNOPQ]ha$gdC*h$d%d&d'dNOPQ]hgdC-$h$d%d&d'dNOPQ]ha$gdC PQ_`acno}Ƿxjx_x_PEh*<hCCJaJjh*<hCCJUaJh*<hCB*phjh*<hCU h*<hCjh*<hCU.jXh*<hC5CJOJQJUaJ(jh*<hC5CJOJQJUaJh*<hC5CJOJQJaJh*<hCCJOJQJaJ%jh*<hCCJOJQJUaJ+jh*<hCCJOJQJUaJ}~=WXY[\^_abdz{Ӷ~vrvrvrvrmeaaVh9h9CJaJhE~hE~hE~5 hE~5hjhU hChS{bhCh*<hC5B*phj(h*<hCU h*<hCjh*<hCUh*<hCB*ph#jh*<hCCJUaJh*<hCCJaJjh*<hCCJUaJ#j@h*<hCCJUaJ `acd{| S 3!!!!!!gdCgdE~$ Q'p&]^a$gdE~$a$gd9gdE~$a$gdE~  , R S | 3!N!O!|!}!!!!!!!!!!!vvevve jh9hE~CJUaJ*jh9hE~CJUaJjh9hE~CJUaJh9hE~CJaJ!h9hE~B*OJQJaJphhFhE~5hC hE~5hE~ jh9h9CJUaJ*hCCJaJmHnHu*h9h9CJaJjh9h9CJUaJ%!!!!! hChS{bhhE~ h9hE~9 0&P1h:pE~/ =!"#$% tDeCheck4tDeCheck5tDeCheck6tDeCheck6tDeCheck6tDeCheck6tDeCheck7tDeCheck7tDeCheck7tDeCheck7tDeCheck7tDeCheck7tDeCheck7tDeCheck1tDeCheck1tDeCheck1tDeCheck7tDeCheck8tDeCheck1QCDd:9tj  c FA"Brand_state-blue2BMJ1b }7oB`!gBMJ1b }7n( #xutE8f̮Q =. 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