STATES - NFPCAR

[Pages:7]

|Requirements |States | |

|Own Form |AL, CA, CO, CT, DC, IL, IN, IA, MD, MN, NV, | These states REQUIRE requests for information to be submitted on the forms they |

| |NY, NC, PA, SC, SD, TX, UT, VA, WA |have developed. Links to forms or websites are provided. |

|Notary |AR, CO, DC, MD, NY, SC, SD, TN, VA |Best to use their form, except for TN. |

|Witness |AL, NE, RI, SC, TX |SC will accept notary or witness, TX requires both. |

|Fee |CA - $15, CO - $30, MN - $20, |Processing fees are reimbursable under Title IV-E administrative expenses. |

| |PA - $10, SC - $8, VA - $5, | |

| |WY - $8 | |

|Original Sig. |DC, NC, SD, TX, WV, WY, Guam | |

|Picture ID |AK, UT | |

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Alabama |CAN Central Registry |Form: DHR-FCS-1598 CAN Central Registry Clearance |

| |Office of Child Protective Services |Form Required? Yes |

| |Department of Human Resources |Call Central Clearinghouse (334) 242-9500 for forms and instructions |

| |50 Ripley Street | |

| |Montgomery, AL 36130-4000 |Signed release required? Yes, and witnessed |

| | | |

| |Phone: (334) 353-1045 |Methods of transmission: Original signature required, mail only |

| |Fax: (334) 242-0939 | |

| | |Fee: no |

| |Contact: Sue Ash, Supervisor | |

| |Email: sue.ash@dhr. | |

|Alaska |Department of Health & Social Services |Form: 06-9437 LIC Clearance Form - Confidential |

| |323 East 4th Avenue |Go to: AK Form |

| |Anchorage, AK 99051 |Form Required? No – but would like a photo ID |

| | | |

| |Phone: (907) 269-4026 |Signed release required? Yes |

| |Fax: (907) 269-4098 | |

| | |Methods of transmission: Mail, email or fax |

| |Contact: Ken Saucier or | |

| |Brandy Aldridge |Fee: no |

| |Email: Kenneth.Saucier@ | |

| | |*Allow 30 days for response |

|Arizona |Arizona Dept. of Economic Security |Form: Yes |

| |CPS Central Registry |Put on agency letterhead. Include the information you are requesting, purpose of |

| |P.O. Box 44240 |request, include the person's names, DOB, SS#, and known addresses in state. |

| |Phoenix, AZ 85064-4240 |Form Required? No |

| | | |

| |Phone: (602) 364-2732 |Signed release required? Yes |

| |Fax: (602) 530-1833 | |

| | |Methods of transmission: Mail or Fax |

| |Contact: Myrrhianna Morningstar | |

| | |Fee: no |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Arkansas |Arkansas Child Maltreatment Central Registry |Form: Authorization for Release of Confidential Information |

| |P. O. Box 1437, Slot S 566 |Go to: Arkansas form |

| |Little Rock, AR 72203 |Send Arkansas form and standard cover letter on letterhead |

| | |Form Required? No |

| |Phone: (501) 682-0402 | |

| |Toll Free: (800) 482-5964 |Signed release required? Yes and notarized |

| |Fax: (501) 682-0407 | |

| |Attn: V. Williams |Methods of transmission: Fax preferred |

| | | |

| | |Fee: no |

|California |California Dept. of Justice |Form: No - See info on DOJ site - CA DOJ Website |

| |Bureau of Criminal Information & Analysis |Form Required? No |

| |Child Protection Program | |

| |Attn: Sharon Wong |Signed release required? Yes |

| |P.O. Box 903387 | |

| |Sacramento, CA 94203-3870 |Methods of transmission: Original signature required, mail only |

| | | |

| |Phone: sharon.wong@doj. |Fee: $15 Note: Processing fees are reimbursable under Title IV-E administrative |

| | |expenses. |

| | | |

| | |More info on DSS Adam Walsh Website: CDSS Adam Walsh |

|Colorado |Background Investigations Unit, Colorado |Form: BIU Individual Inquiry Form (do not use the facility form) |

| |Department of Human Services (BIU, CDHS) | CO Form |

| |3550 W. Oxford Avenue |Form Required? Yes |

| |Denver, CO 80236 | |

| | |Signed release required? Yes, and notarized |

| |Phone: (303) 866-7100 | |

| | |Methods of transmission: Original signature required, mail only |

| |Contacts: | |

| |Helen Artz (303) 866-7183 |Fee: $30.00 made payable to CDHS, BIU. Note: Processing fees are reimbursable under |

| |Jan Diaz (303) 866-7230 |Title IV-E administrative expenses. |

| |Valerie Fresquez (303) 866-7925 (a.m. only) | |

| |valerie.fresquez@state.co.us |Website |

| |Rose Estrada, Mgr. (303) 866-7187 | |

|Connecticut |Department of Children and Families |Form: Authorization for Release of Information for DCF CPS Search |

| |Hotline |Form Required? Yes |

| |Fifth Floor |Go to: CT form |

| |505 Hudson Street | |

| |Hartford, CT 06106 |Signed release required? Yes, see instructions at website link |

| | | |

| |Phone: (800) 842-2288 |Methods of transmission: Mail or fax |

| |Phone: (860) 560-7000 | |

| |Fax: (860) 560-7072 |Fee: No |

| | | |

| |Contact: Buck Gregory |Website |

| |Email: BUCK.GREGORY@ | |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Delaware |Department of Services for Children, Youth & |Form: Consent to Release Child Protection Registry Information. |

| |Their Families |Go to: DE Form |

| |1825 Falkland Road |Form Required? No. Print form on letterhead. Requests should state that the |

| |Wilmington, DE 19805 |information is required to comply with the Adam Walsh Child Protection and Safety |

| | |Act of 2006. |

| |Phone: (302) 892-5814 | |

| |Phone: (800) 292-9582 |Signed release required? Yes |

| |Fax: (302) 633-5191 | |

| |(Do not fax on Wednesdays) |Methods of transmission: Mail or fax |

| | | |

| |Contact: Beth Kramer |Fee: No |

| | | |

| | |Website:  |

|District of |Child Protection Registry |Form: Yes |

|Columbia |400 Sixth Street, SW |Go to: DC Form |

| |Washington, DC 20024 |Form Required? Yes |

| | | |

| |Phone: (202) 727-8885 |Signed release required? Yes and notarized |

| |Fax: (202) 727-8040 | |

| | |Method of transmission: Mail only, original signature required |

| | | |

| | |Fee: No |

| | |Website:  |

|Florida |Department of Children & Families |Form: CF 1651 Central Abuse Hotline Record Search |

| |1317 Winewood Blvd. |Go to: Florida form |

| |Tallahassee, FL 32399 |Form Required? No. Print form on letterhead. |

| | | |

| |Phone: (850) 487-6123 |Signed release required? Yes |

| |Fax: (850) 488-1319 | |

| | |Methods of transmission: Mail or fax |

| |Contact: Sandy Pillar | |

| |Email: sandy_pillar@dcf.state.fl.us |Fee: No |

| | | |

| | |Website: |

|Georgia |Deborah Gibson |Form: No |

| |DHR, DCFS |Form Required? No. Print request for information on letterhead. Request must include|

| |2 Peachtree St. NW, Ste. 18-494 |DOB, SS# and last known address in Georgia |

| |Atlanta, GA 30303 | |

| | |Signed release required? No |

| |Phone: (404) 657-8961 | |

| |Fax: (404) 657-3415 |Methods of transmission: Fax |

| | |Fee: No |

| |Email: dmgibson@dhr.state.ga.us | |

|Guam |Bureau of Social Services Administration |Form: No |

| |Department of Public Health & Social Services |Form Required? No. Print request for information on letterhead. |

| |194 Hernan Cortez Avenue | |

| |Hagatna, Guam  96910 |Signed release required? Yes |

| |Phone: (671) 475-2653/2672 | |

| |Fax:  (671) 477-0500 |Methods of transmission: Will accept email or Fax to expedite process, but requires |

| |Email: lydia.tenorio@dphss. |original form by mail to release information |

| | | |

| | |Fee: No |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Hawaii |Hawaii Department of Human Services |Form: No |

| |420 Waiakamilo Road, #300B |Form Required? No. Print request on letterhead. |

| |Honolulu, HI 96817 | |

| | |Signed release required? No |

| |Phone: (808) 832-0609 | |

| | |Methods of transmission: Original signature required, mail only |

| |Contact: Cynthia Goss | |

| |Email: cgoss@dhs. |Fee: No |

| | | |

| | |Website:  Call for more information |

|Idaho |Idaho Department of Health & Welfare |Form: Yes-Authorization & Consent to Release Information |

| |Children & Family Services |Go to: ID Form |

| |450 W. State Street, 5th Floor |Form Required? No. Print request on letterhead. |

| |PO Box 83720 | |

| |Boise, ID 83720-0036 |Signed release required? Yes – specifically authorize Idaho to release information |

| | | |

| |Phone: (208) 334-5690 |Methods of transmission: Mail |

| | | |

| |Contact: Tina Griffin |Fee: No |

| |Email: griffinT2@dhw. | |

| | | |

| | |Website:  |

|Illinois |Department of Family & Children Services |Form: CFS 689 Authorization for Background Check |

| |406 E. Monroe Street, Station 30 |Go to: |

| |Springfield, IL 62701 |[pic] |

| | |Form Required? Yes |

| |Fax: (217) 785-6580 | |

| |attn: Linda Smith |Signed release required? Yes |

| | | |

| |Contact: Linda Smith |Methods of transmission: Mail and fax |

| |Email: linda.smith2@ | |

| | |Fee: No |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Indiana |Indiana Dept. of Child Services |Form: Yes 52802 Request for a Child Protection Services (CPS) |

| |Background Check Unit |History Check |

| |302 W. Washington |Go to: IN Form |

| |Room E306-MS08 |Form Required? Yes – Always include maiden and all married names for female applicants|

| |Indianapolis, IN 46204 | |

| | |Signed release required? Yes |

| |Phone: (317) 234-5790 | |

| |Fax: (317) 234-4633 |Methods of transmission: Fax or mail |

| |Toll-Free: (800) 800-5556 | |

| | |Fee: No |

| |Contact: Vonda Ramsey | |

| |Email: Background.CheckUnit@dcs. |Website:  |

|Iowa |Iowa Central Abuse Registry |Form: 470-0643 Request for Child Abuse Information |

| |Iowa Dept. Of Human Services |Go to: IA Form |

| |1305 E. Walnut, 5th Floor, Hoover Building |Form Required? Yes |

| |Des Moines, IA 50319 | |

| | |Signed release required? No |

| |Toll-Free: (800) 362-2178 | |

| |Phone: (515) 281-5581 |Methods of transmission: Fax only |

| |Fax: (515) 242-6884 | |

| | |Fee: No |

| |Contact: Linda Chagoya |Website:  |

|Kansas |SRS / Children & Family Services |Form: No |

| |915 SW Harrison Street, 5th Floor South |Form Required? No. Print request on letterhead. |

| |Topeka, KS 66613 | |

| | |Signed release required? No |

| |Phone: | |

| |Janna (785) 296-5636 |Methods of transmission: Mail or fax |

| |Annette (785) 296-6783 | |

| |Fax: (785) 296-0470 |Fee: No |

| | | |

| |Contacts: Janna Gunckle or |Website:  |

| |Annette Caraway | |

| |Email: janna.gunckle@srs. | |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Kentucky |Department for Community Based Services |Form: No |

| |Records Management Section |Form Required? No. Print request on letterhead. |

| |275 East main Street, 3E-G | |

| |Frankfort, KY 40621 |Signed release required? No |

| | | |

| |Phone: (502) 564-3834 x 4455 |Methods of transmission: Mail or fax |

| |Toll-Free: (800) 752-6200 | |

| |Fax : (502) 564-9554 |Fee: No |

| | | |

| |Contact: David Smith | |

| |Email: DavidF.Smith@ | |

| | |Website:  |

|Louisiana |Louisiana Department Social Services |Form: No |

| |Office of Community Services |Form Required? No. Print request on letterhead. |

| |Attention CPI Section – Intake | |

| |P.O. Box 3318 |Signed release required? No |

| |Baton Rouge, LA 70821 | |

| | |Methods of transmission: Email, Fax, Mail |

| |Phone:  (225) 342-8631 | |

| |Fax:  (225) 342-9087 |Fee: No |

| | | |

| |Email: dnether1@dss.state.la.us |Website  |

|Maine |Department of Health & Human Services |Form: No |

| |Office of Child & Family Services |Form Required? No. Print request on letterhead. |

| |Child Protective Intake Unit | |

| |11 State House Station |Signed release required? No |

| |Augusta, ME 04333 | |

| | |Methods of transmission: Mail or fax |

| |Phone: (800) 452-1999 | |

| |Fax: (207) 287-5065 |Fee: No |

| | | |

| |Contact: Robert Pronovost |Responses will provide only summary information concerning any maltreatment findings |

| |Email: Robert.n.pronovost@ | |

| | |Website:  |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Maryland |Maryland Department of Human Resources |Form: DHR/SSA 1279 Consent for Release of Information/Background Clearance Request |

| |In-Home Services |Go to: MD Form |

| |Social Services Administration |Form Required? Yes |

| |311 W. Saratoga Street, Room 553 | |

| |Baltimore, MD 21201 |Signed release required? Yes and notarized |

| | | |

| |Contact Center Verification |Methods of transmission: Original signature required, mail only |

| |for Foster Care | |

| |Phone: (800) 332-6347 |Fee: No |

| | | |

| | |Website |

|Massachusetts |Department of Social Services |Form: No |

| |24 Farnsworth Street |Form Required? No. Print request on letterhead |

| |Boston, MA 02210 | |

| | |Signed release required? No |

| |Phone: (617) 748-2079 | |

| |Toll Free: (800) 792-5200 |Methods of transmission: Mail or fax |

| |Fax: (617) 439-9027 | |

| | |Fee: No |

| |Contact: Kim Sportman | |

| |Email: kim.sportman@state.ma.us |Website |

|Michigan |Michigan Department of Human Services |Form: No |

| |Bureau of Adult & Child Licensing | |

| |P.O. Box 30037 |Form Required? No. Print request on letterhead & include following: reason for |

| |Lansing, MI 48909 |request, family names, DOB, SS# |

| | | |

| |Phone: (517) 335-3704 |Signed release required? No |

| |Toll free:  (866) 685-0006 | |

| |Fax: (517) 335-6121  |Methods of transmission: Mail or fax |

| | | |

| | |Fee: No |

| | | |

| | |Website |

|Minnesota |Minnesota Department of Human Services |Form: Consent/Authorization for Release of Information from Minnesota Child Abuse and|

| |Background Studies Unit |Neglect Registry |

| |P.O. Box 64242 |Form Required? Yes [pic] |

| |St. Paul, MN 55164-0242 | |

| | |Signed release required? Yes |

| |Phone: (651) 296-2075 | |

| |Fax: (651) 297-1490 |Methods of transmission: Mail |

| | | |

| |Contact: Lori Steffan or |Fee: $20 to Minn. Dept. of Human Services, Note: Processing fees are reimbursable |

| |Stephan Sarumi |under Title IV-E administrative expenses. |

| | | |

| | |Website |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Mississippi |Dept. of Human Services |Form: No |

| |Protection Unit |Form Required? No. Print request on letterhead. Include stamped return envelope. |

| |P. O. Box 352 | |

| |Jackson, MS 39205-0352 |Signed release required? Yes |

| | | |

| |Toll-Free: (800) 222-8000 |Methods of transmission: Mail |

| |Phone: (601) 359-4487 | |

| |Fax: (601) 576-2584 |Fee: No |

| | | |

| |Contact: Pearl Holloway |Website: |

|Missouri |Missouri Department of Social Services |Form: MO 821-0353 Request for Child Abuse or Neglect/Criminal Record |

| |Children’s Division |Go to: [pic] |

| |P.O. Box 88 |Form Required? No. Print request on letterhead |

| |Jefferson City, MO 65103 | |

| | |Signed release required? Yes |

| |Phone: (573) 751-2330 | |

| |Fax: (573) 751-2607 |Methods of transmission: Mail, email or fax |

| | | |

| |Contact; Martha Witt |Fee: No |

| |Background & Screening Unit | |

| |Email: Martha.S.Witt@dss. |Website: |

|Montana |Montana Child & Family Services Division |Form: No |

| |Centralized Intake Unit |Form Required? No. Print request on letterhead |

| |PO Box 8005 | |

| |Helena, MT 59604 |Signed release required? Yes |

| | | |

| |Phone: (406) 444-4164 |Methods of transmission: Mail or fax |

| |Toll-Free: (866) 820-5437 | |

| |Fax: (406) 444-4156 |Fee: No |

| | | |

| |Contact: Ryan Tofflemire |Website:  |

| |Email: rtofflemire@ | |

|Nebraska |Nebraska Health & Human Services |Form: Yes |

| |P.O. Box 95026 |Form Required? No. Print request on letterhead |

| |Lincoln, NE 68509-5026 | |

| | |Signed release required? Yes, and witnessed |

| |Phone: (401) 471-9625 | |

| |Fax: (402) 471-9034 |Methods of transmission: Mail, email or fax |

| | | |

| |Contact: Patti Reddick |Fee: No |

| |Email: patti.reddick@dhhs. | |

| | |Website:  |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Nevada |Nevada Central Registry | Form: NV-Form 3069a: Request for Central Registry Data by Non-Licensing Entity |

| |Nevada Division of Child & Family Services |Go to: NV Form |

| |4126 Technology Way, 3rd Floor |Form Required? Yes |

| |Carson City, NV 89706 | |

| | |Signed release required? Yes |

| |Phone: (775) 684-4415 | |

| |Fax: (775)684-4455 |Methods of transmission: Mail or fax |

| | | |

| |Contact: Angelique Corum |Fee: No |

| | | |

| | |Website:  |

|New Hampshire |NHDCYF Central Registry |Form: 2202 Central Registry Name Search Authorization [pic] |

| |129 Pleasant Street |Form Required? No |

| |Concord, NH 03301 | |

| | |Signed release required? Yes |

| |Toll-Free: (800) 894-5533 | |

| |Phone: (603) 271-4684 |Methods of transmission: Mail or fax |

| |Fax: (603) 271-6565 | |

| | |Fee: No |

| |Contact: John Harrington | |

| | |Website:  |

|New Jersey |Department of Children & Families |Form: No |

| |Office of Licensing/CARI Unit |Form Required? No. Print request on agency letterhead, include state statute citation,|

| |P.O. Box 717 |and identify individual and program. Send your stat’s completed form including release|

| |Trenton, NJ 08625-0717 |of information |

| | | |

| |Phone: (609) 987-2028 |Signed release required? Yes |

| |Phone: (609) 826-3906 | |

| | |Methods of transmission: Mail |

| |Contact: Richard Ferrell | |

| | |Fee: No |

| | | |

| | |Website:  |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|New Mexico |CYFD-PS |Form: No |

| |PO Drawer 5160 |Form Required? No. Print request on letterhead |

| |PERA Room 254 | |

| |Santa Fe, NM 87502 |Signed release required? No |

| | | |

| |Toll-Free: (800) 797-3260 |Methods of transmission: Mail or fax |

| |Phone: (505) 841-6100 | |

| |Fax: (505) 476-5490 |Fee: No |

| | | |

| |Contact: Loretta Perea |Website:  |

|New York |Office of Children & Family Services |Form: LDSS-3370 Statewide Central   |

| |New York State Central Register |Go to: [pic] |

| |P.O. Box 4480 |Form Required? Yes |

| |Albany, NY 12204 | |

| | |Signed release required? Yes and notarized |

| |Toll-Free: (800) 342-3720 | |

| |Phone: (518) 474-8740 |Methods of transmission: Mail or fax |

| |Fax: (518) 486-3424 | |

| | |Fee: No |

| |Contact: Roberta Frederick | |

| | |Website: |

|North Carolina |North Carolina Division of Social Services |Form: DSS-5268 FSCWS Request for Information from the Responsible Individuals List |

| |Regulatory & Licensing Services |Go to: NC Form |

| |Attn:RIL |Form Required? Yes |

| |952 Old U.S. 70 Highway | |

| |Black Mountain, NC 28711 |Signed release required? Yes with original signature |

| | | |

| |Phone: (919) 733-4622 x322 |Methods of transmission: Original signature required, mail only |

| | | |

| |Contact: Terri Reichert |Fee: No |

| |Email: terri.reichert@ | |

| | |Website |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|North Dakota |Department of Human Services |Form: SFN 838 Personal Authorization for Criminal History Background Check |

| |Children & Family Services |Inquiry-Foster Care of Children; Legal Guardian of Children or Adoption |

| |600 E. Boulevard Avenue, Dept 325 |[pic] |

| |Bismarck, ND 58505-0250 |Form Required? No |

| | | |

| |Phone: (701) 328-3587 |Signed release required? Yes |

| | | |

| |Contact: Tara Lea Muhlhauser |Methods of transmission: Original signature required, mail only |

| |Email: somuhl@state.nd.us | |

| | |Fee: No |

| | | |

| | |Website |

|Ohio |Ohio Dept. of Job & Family Services |Form: No |

| |Office for Children & Family Services |Form Required? No. Print request on letterhead. Include statement that search is |

| |PO Box 182709 |required by for Adam Walsh Child Protection and Safety Act of 2006 |

| |Columbus, OH 43218-2709 | |

| | |Signed release required? No |

| |Phone: (614) 752-1298 | |

| |Fax: (614) 728-6726 |Methods of transmission: Email or fax |

| |(866) 635-3748 OPTION 2 | |

| | |Fee: No |

| |Contact: Barbara Parker | |

| |Email: parkeb@odjfs.state.oh.us |Website |

|Oklahoma |Oklahoma Department of Human Services |No registry |

| |Children & Family Services Division | |

| |Attn: Robert Hadden |All requests must be faxed on company letterhead to Robert Hadden, and should include |

| |PO Box 25352 |the purpose of request, names/identifying information of family members, and a return |

| |Oklahoma City, OK 73125 |fax number |

| | | |

| |Fax: (405) 521-4373 | |

| | | |

| |Email: Robert.Hadden@ | |

| | | |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Oregon |Oregon Department of Human Services |Form: No |

| |P.O. Box 14870 |Form Required? No |

| |Salem, OR 97309-5066 | |

| | |Signed release required? No |

| |Phone: (503) 378-5632 | |

| |Fax: (503) 378-6314 |Methods of transmission: Mail or fax |

| | | |

| |Attn: Michelle Grimes |Fee: No |

| |Email: Michelle.A.Grimes@state.or.us | |

| | |Website |

|Pennsylvania |ChildLine & Abuse Registry |Form: CY 113 Pennsylvania Child Abuse History Clearance Form |

| |Department of Public Welfare |Go to: PA Form |

| |PO Box 8170 |Form Required? Yes |

| |Harrisburg, PA 17105-8170 | |

| | |Signed release required? No |

| |Phone: (717) 772-6574 | |

| |Toll-Free: (800) 932-0313 |Methods of transmission: Original signature required, mail only |

| | | |

| |Contact: Kevin Fisher |Fee: $10 fee to Dept. of Public Welfare |

| |Email: Kefisher@state.pa.us | |

| | |Website |

|Puerto Rico |Directora Centro Estatal |Form: No |

| |Sevilla Plaza |Form Required? No |

| |Calle Sevilla #58 | |

| |Hato Rey, PR 00917 |Signed release required? No |

| | | |

| |Phone: (787) 625-4957 |Methods of transmission: Mail or fax |

| | | |

| |Contact: Ms. Iris Colón Casteñeda |Fee: No |

| |or Lisa Agosto Carrasquillo | |

| | |Not clear if there is a registry for child abuse. There is a sexual offender registry|

| | | |

| | |Spanish Information on Website:  |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Rhode Island |Rhode Island State Central Registry & Child |Form: No |

| |Abuse Hotline |Form Required? Request on state letterhead |

| |DCYF | |

| |101 Friendship St, 2nd Floor |Signed release required? Yes, and witnessed |

| |Providence, RI 02903 | |

| | |Methods of transmission: Fax or Email |

| |Phone: (800) 742-4453 | |

| |(401) 528-3843 |Fee: No |

| | | |

| |Contact: Maria Butts |Website |

| |Email: Maria.butts@dcyf. | |

|South Carolina |South Carolina Department of Social Services |Form: DSS Form 3072 Consent to Release Information |

| |Central Registry |Go to: SC Form |

| |P.O. Box 1520 |Form Required? Yes. |

| |Columbia, SC 29202-1520 | |

| | |Signed release required? Yes, witnessed or notarized |

| |Phone: (803) 898-7318 | |

| |Fax: (803) 898-7641 |Methods of transmission: Original signature required, mail only |

| | | |

| |Contact: Virginia Oliver |Fee: $8 |

| |or Beth Williams | |

| |Email: Virginia.Oliver@dss. |Website:  |

| |Beth.Williams@dss. | |

|South Dakota |Department of Social Services/CPS |Form: Yes. Contact by phone for instructions. |

| |700 Governors Drive |Form Required? Yes |

| |Pierre, SD 57501-2291 | |

| | |Signed release required? Yes, witnessed and notarized |

| |Phone: (605) 773-3227 | |

| | |Methods of transmission: Mail, original required |

| |Contact: Penny Tople | |

| |Email: le@state.sd.us |Fee: No |

| | | |

| | |Website:  |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Tennessee |Jerry Cunningham, |Form: No |

| |Division of Centralized Permanency |Form Required? No |

| |Office of Child Permanency | |

| |436th Avenue North |Signed release required? Yes |

| |Nashville, TN 37243 | |

| | |Methods of transmission: Mail, Email, Fax |

| |Phone: (615) 532-9700 | |

| |Fax: (615) 532-6495 |Fee: No |

| | | |

| |Email: jerry.cunningham@state.tn.us |Website |

|Texas |Texas Department of Family & Protective |Form: 2970 Request for Child Abuse/Neglect Central Registry Check [pic] |

| |Services |Form Required? Yes |

| |Centralized Background Check Unit | |

| |PO Box 149030 |Signed release required? Yes, witnessed AND notarized |

| |Mail Code 121-7 | |

| |Austin, TX 78714-9030 |Methods of transmission: Original signature required, mail only |

| | | |

| |Fax: (512) 339-5871 |Fee: No |

| | | |

| |Contacts: |physical address: 2525 Ridgepoint Drive, Austin, TX 78754 |

| |Tri Dang (512) 919-7823 | |

| |Tri.Dang@dfps.state.tx.us |Website |

| |Cindy Laurence (512) 919-7824 | |

| |Cassandra Beno (512) 919-7823 | |

| |Jessica Ramirez (512) 919-7818 | |

| |Jennifer Thompson (512) 919-7819 | |

|Utah |Division of Child & Family Services |Form: Informed Consent and Release of Liability |

| |Department of Human Services |Go to: UT Form |

| |120 North 200 West, Suite 225 |Form Required? Yes |

| |Salt Lake City, UT 84103-1500 | |

| | |Signed release required? Yes |

| |Phone: (801) 538-4061 | |

| |Fax: (801) 538-3993 |Methods of transmission: Mail or fax, also include a copy of the person’s picture |

| | |identification |

| |Contact: Cherri Joy | |

| |Email: cjoy@ |Fee: No |

| | | |

| | |Website:  |

|Vermont |Child Abuse Registry Unit |Form: Request for Information from the Vermont Child Abuse & Neglect Registry [pic]|

| |Department for Children & Families |Form Required? No |

| |Family Services Division | |

| |103 South Main Street |Signed release required? No |

| |Waterbury, VT 05671-2401 | |

| | |Methods of transmission: Mail, email or fax |

| |Phone: (802) 241-2131 | |

| |General: (800) 649-5285 |Fee: No |

| |Fax: (802) 241-2407 | |

| | |Website:  |

| |Contact: Fred Ober | |

| |Email: frederick.ober@ahs.state.vt.us | |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Virginia |Virginia Department of Social Services |Form: 032-02-0151-07 Central Registry Release of Information Form |

| |Child Abuse Central Registry Unit |Go to: VA Form |

| |7 N. Eighth Street, 4th Floor |Form Required? Yes |

| |Richmond, VA 23219 | |

| | |Signed release required? Yes, and notarized (complete Certification section of form |

| |Phone: (804) 726-7567 |and attach notary form) |

| |Toll-Free: (800) 552-7096 | |

| |Fax: (804) 726-7895 |Methods of transmission: Original signature required, mail only |

| | | |

| |Contact: Betty Whittaker, Central Registry |Fee: Yes - $5 |

| |Supervisor | |

| |Email: betty.whittaker@dss. |Website:  |

|Washington |Children’s Administration |Form: Washington State Child Abuse and Neglect Findings Request |

| |NCIC Access Unit |Go to: WA Form |

| |Attn: CAN History Check |Form Required? Yes |

| |P.O. Box 4369 | |

| |Seattle, WA 98194 |Signed release required? Yes |

| | | |

| |Phone: (800) 562-5624 |Methods of transmission: Mail, email and fax |

| |Fax: (206) 341-7930 | |

| | |Fee: No |

| |Contact: Cheryl Rich | |

| |Email: rcch300@dshs. |Website |

| |childabuseregistry@dshs. | |

|West Virginia |West Virginia Department of Health & Human |Form: BCF-PSRC Authorization and Release for Protective Services Record Check |

| |Resources |Go to: WV Form |

| |350 Capitol Street, RM 691 |Form Required? No |

| |Charleston, WV 25301 | |

| | |Signed release required? Yes, require original signature |

| |Phone: (304) 558-4408 | |

| |Toll-Free: (800) 352-6513 |Methods of transmission: Original signature required, mail only |

| |Fax (304) 558-5354 | |

| | |Fee: No |

| |Contact: Cher O’Brien | |

| |Email: fc697@ |Website:  |

|Wisconsin |Division of Children & Family Services |Form: No |

| |Child Protective Services |Form Required? No. Print request on letterhead |

| |Contact: Julie Bachir | |

| |P.O. Box 8916 |See Page 4 of: WI Procs |

| |Madison, WI 53708-8916 |For information request procedure |

| | | |

| |Phone: (888) 787-0376 |Signed release required? Yes |

| |Fax: (608) 266-0260 | |

| | |Methods of transmission: Mail or fax |

| |Email: BachiJS@dhfs.state.wi.us | |

| | |Fee: Not at state level but counties may charge a fee |

| | |No Central Registry |

| | |Website |

Updates for information listed here should be directed to: Linda.Estelle@dss.

|NOTE to California FFH and FFAs: When completing another state’s form, CDSS Adam Walsh Unit must always be the “Requestor.” |

|NOTE to California County Licensing Agencies: When completing another state’s form, always identify your office as the “Requestor.” |

|The subject of the inquiry is NOT the “Requestor.” |

|State |Contact Information |Procedures / Forms |

|Wyoming |Department of Family Services |Form: SS-26 Application for Child Abuse/Neglect and Adult Central Registry Screens |

| |Attn: Kathy Garcia |and Wyoming Criminal History Record Prescreens [pic] |

| |2300 Capitol, 3rd Floor |Form Required? No. They prefer their form but will accept others. |

| |Cheyenne, WY 82001 | |

| | |Signed release required? Yes with original signature |

| |Phone: (307) 777-5894 | |

| |Fax: (307) 777-3659 |Methods of transmission: Original signature required, mail only |

| | | |

| |Email: KGarci@state.wy.us |Fee: $8.00 |

| | | |

| | |Website |

Updates for information listed here should be directed to: Linda.Estelle@dss.

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