Tennessee
|[pic] |Tennessee Department of Children’s Services |
| |Waiver of Criminal Convictions, Pre and In-Service Training Requirements, Non- Safety Issues, CPS Substantiations and Education Requirements |
|Requesting Agency/DCS Region: | |Telephone No.: |( ) - |
|Employee/Foster Home Name: | |
|Household Member Requiring Waiver (Foster Home only): | |
|Household Member Address: | |
|Household Member Phone Number: | |
|Type of Waiver: | Education | Misdemeanor Conviction | Felony Convictions |
|CPS Substantiation |Non-Safety Issue |Excess of 5 Conviction |Pre & In-Service Training |
|*In the case of an expedited placement of a child, any needed waiver of any CPS substantiations and/or felony criminal convictions must be fully approved by|
|the Regional Administrator and the Central Office staff prior to placement. |
|Conviction Description: (i.e. | |County/State of Disposition: | |Date of Conviction: | |
|Robbery, DUI) | |(i.e. Knox/TN) | | | |
|CPS Classification Type: | |County/State of | |Date of Substantiation: | |
| | |Substantiation: | | | |
|Pre-Service Training: | | | | |
|TN KEY Modification Type: | Extension | Equivalent | Individual | ICPC Condensed* |
| | Exemption | Modified Schedule |*Relative/Kin Only |
| | |
|In-Service Training: |
| CPR/First Aid Equivalent | Working with the Education System |In-Service Training | Deferred |
| | | |Exemption |
|Exp. Date for CPR/First Aid Equivalent: ________ (to be entered by Central Office staff at time of approval) |
| Medical Professional Medication Administration Exemption |
|Circumstances and Justification of the Waiver request (Attach supporting documentation of criminal history results or supporting training documentation): |
| |
For Foster Homes and Employees:
| | Approved | |
| |Denied | |
|Regional Administrator/Designee Signature | |Date |
| | Approved | |
| |Denied | |
|Contract Agency Executive Director/Designee Signature | |Date |
| | Approved | |
| |Denied | |
|Executive Director of Child Programs/Designee Signature | |Date |
| | Approved | |
| |Denied | |
|Director of Licensure/Designee Signature | |Date |
For Training Exceptions:
| | Approved | |
| |Denied | |
|Director of Training and Professional Development/Designee Signature | |Date |
| | Approved | |
| |Denied | |
|Director of Health Advocacy/Designee Signature | |Date |
|Employee/Foster Home Name: | |
For DCS Employees Only:
| | Approved | |
| |Denied | |
|Executive Director of Human Resources/Designee Signature | |Date |
| | Approved | |
| |Denied | |
|Deputy Commissioner/Designee-Juvenile Justice Signature | |Date |
For CPS Substantiations:
| | Approved | |
| |Denied | |
|Executive Director Child Safety/Designee Signature | |Date |
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