Worker Registration - Missouri Department Of Health And Senior Services

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Missouri Department of Health and Senior Services

FCSR USE ONLY

Family Care Safety Registry

RESET

OR mail this form, copy of

Social Security card, and payment to Missouri Dept. of Health and

WORKER REGISTRATION

Senior Services, Fee Receipts, PO Box 570, Jefferson City, MO 65102.

REGISTRATION TYPE (Check all that apply. Complete column on right only if Long Term Care/Personal Care selected from left.)

Adoptive Parent (Agency Name:

)

Long Term Care / Personal Care

Subcategories

Child Care

(Complete if LTC/PC selected at left.)

Foster Parent/Family Member of Foster Parent (County Office:

)

Adult Day Care

Hospital

Assisted Living Facility



Long Term Care/Personal Care (Please choose subcategory at right

Hospice

Mental Health/Psychiatric Hospital

Hospital LTAC/Swing Bed

Voluntary (Select voluntary if no other registration type applies.)

Mental Health – Residential Facility/ICF

$13.00

A one-time registration fee of

applies to all categories except Foster

Nursing Facility/Skilled Nursing

Parents. Foster Parents must list the Children’s Division county office.

Personal Care – Home Health

Personal Care – In-Home Services

website at

or call, toll free, 866-422-6872.

Personal Care – Consumer Directed

SOCIAL SECURITY NUMBER (Mail copy of card with form.)

Services/Center for Independent Living

—

Personal Care – HCY/PDW/DDD/Other

PERSONAL INFORMATION (Provide all names you have used, starting with most recent. Include legal names and nicknames.)

LAST NAME

FIRST NAME

MIDDLE NAME

SUFFIX

(Jr., Sr., II, III)

MAIDEN NAME (If applicable)

PRIOR NAMES USED (If applicable, list first and last names.)

DATE OF BIRTH (mm-dd-yyyy)

GENDER

CONTACT INFORMATION

MAILING ADDRESS (Enter your street address or post office box. This address must be different from Employer Address.)

CITY

STATE

ZIP CODE

COUNTY

EMAIL ADDRESS (Required)

TELEPHONE

COUNTRY (Complete only if U.S. territory/outside U.S.)

(

)

EMPLOYER ASSOCIATED WITH THIS REGISTRATION (Complete either left or right column, not both.)

My current/potential child care, long term care or mental health care employer is:

No Employer, because I am a(n):

EMPLOYER NAME

Adoptive Parent

Foster Parent/Family Member

EMPLOYER ADDRESS

Home Child Care Provider

Private Pay/Private Duty

EMPLOYER CITY

STATE

ZIP

Student

Volunteer

)

Other (Explain:

EMPLOYER TELEPHONE

EMPLOYER CONTACT NAME

EMPLOYER CONTACT TITLE

(

)

REGISTRATION AGREEMENT

The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this

form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by

law to process this request. Furthermore, I authorize the DHSS to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any

related background information to the requester of the FCSR for employment purposes only, as provided in §210.921, subsection 1, subdivisions (1) and (2),

RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective employer/employee relationships,

and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal

care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy of the transfer of information to the

FCSR within thirty (30) days of receiving the results of the background screening.

NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to my designated bank account. I understand that my

signature below authorizes my financial institution to deduct this payment from my account. In the event that DHSS or its subcontractor is unable to secure

funds from my account or I provide insufficient or inaccurate information regarding my account, my obligation to the DHSS will remain unpaid and further

collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.

DATE OF SIGNATURE (Must be within six months of submission.)

SIGNATURE OF APPLICANT (Must be signed in blue or black ink.)



MO 580-2421 (FP)

Rev. 09/16