Dfps Background Check: Information Collection Form For Casa Employees / Volunteers

ADVERTISEMENT

DFPS Background Check: Information Collection Form for CASA Employees / Volunteers
First Name
Middle Name
Last Name
Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last
Residence Street Address
City
County
State
Zip Code
Residence Telephone Number
Alternate Telephone Number
Date of Birth
Gender :
SSN
Male -
Female
Race (check all applicable)
Ethnicity (check one, only)
Asian
Black
White
Am Indian/AK Native
Hispanic
Not Hispanic
Nat Hawaii/Pac Island
Unable to Determine (or, none of the above)
Unable to Determine
List other places you have resided (for a minimum of the past 5 years)
Eligible for Case Connection: Yes
No
Email Address of the Subject of the Background Check:
I am the person listed above and the information I provided is true and correct. I grant permission to the CASA program to
request a Texas Abuse and Neglect background check through the Texas Department of Family and Protective Services
on my behalf.
Signature: ________________________________________
Date of Consent: ______________________
DFPS Security Agreement for CASA Employees / Volunteers
This agreement is for individuals who are not employees of the Texas Department of Family and Protective Services (DFPS),
but who will be provided confidential information as part of a project, contract, or agreement between DFPS and the organization
the individual represents.
I understand and acknowledge that information made available to me by the Department of Family and
Protective Services contains data that is considered confidential under law. I will use this information
with discretion in performing my duties and responsibilities as a CASA Staff or volunteer and will
disclose this information to other individuals only to the extent that it is specifically authorized under
the contract or agreement in place between my organization and DFPS. If at any time a question or
problem arises with regard to the release of information, I will not release the information until I am so
authorized. Under no circumstances will I access or release confidential information for any purpose
other than in the performance of my duties and responsibilities as a CASA staff or volunteer as they
relate to the contract or agreement with DFPS. I understand that if I use this information in an
unauthorized manner, I may be subject to prosecution under one or more applicable statutes and will
no longer be allowed access to the information provided to my organization.
If I am eligible for access to Case Connection, I acknowledge that I have read and understand the DFPS
Security Requirements provided to me as part of this security agreement.
Attached please find: DFPS Requirements and Guidelines for CASA organizations.
____________________________
_______________
Signature
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Abc-805 - Employee/volunteer Registration Instructions Form Abc-805 - Employee/volunteer Registration Instructions Financial
Form Njbos-4 - Information Request Form For Central Registration Depository And/or Investment Adviser Registration Depository Information Form Njbos-4 - Information Request Form For Central Registration Depository And/or Investment Adviser Registration Depository Information Legal
Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2007 Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2007 Financial
Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2009 Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2009 Financial
Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2010 Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 2010 Financial
Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2004 Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2004 Financial
Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 1999 Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York Hired On Or After January 4, 1973 - 1999 Legal
Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2003 Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2003 Financial
Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2002 Form Nyc 1127 - Form For Nonresident Employees Of The City Of New York - 2002 Financial
Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York - 2001 Form Nyc-1127 - Form For Nonresident Employees Of The City Of New York - 2001 Financial

Related Categories

Parent category: Legal
Download
Go