Form F-500-2854 Request For Child Abuse/neglect Central Registry And Dps Criminal History Check
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1
2Form F-500-2854
New July 2014
REQUEST FOR CHILD ABUSE/NEGLECT CENTRAL
REGISTRY and DPS CRIMINAL HISTORY CHECK
C
O
O
(COO) - C
B
C
U
HIEF
PERATING
FFICER
ENTRALIZED
ACKGROUND
HECK
NIT
Purpose: The purpose of this form is to grant representatives of authorized Volunteer Organizations permission to
request, on the behalf of potential and current volunteers, employees, and board members:
•
a criminal history check from the Texas Department of Public Safety (DPS) and
•
a check from the Texas Department of Family and Protective Services (DFPS) Central Registry of Child
Abuse and Neglect.
The authorized volunteer organizations include: Big Brothers and Big Sisters of America, Child Advocacy Centers of
Texas, Make-A-Wish Foundation of America and I Have a Dream/Houston. This form is completed by the subject of
the background check or a designee.
Directions: The subject of the background check or designee reads and completes Sections 1-5, and submits this
form using the instructions below. For questions, call the CBCU Support Line at (800) 645-7549 or email:
CACTXBGCREQUEST@dfps.state.tx.us.
A note to Designees: The designee is responsible for ensuring the information provided by the subject in Section 1
is complete and accurate. The information must be verified by viewing official documents provided by the subject of
the check, such as a driver’s license or social security card.
Instructions: Complete, sign, and submit this form to:
Email:
CACTXBGCREQUEST@dfps.state.tx.us
Mail: CBCU Non-Licensing Unit M/C 121-7
FAX: 512-339-5831
PO Box 149030, Austin, TX 78714-9030
SECTION 1: SUBJECT OF THE BACKGROUND CHECK
The information in this section must be provided by the subject of the background check before the check is
conducted. Missing information may result in delays.
First Name
Middle Name
Last Name
Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last (continue on back as needed)
Current Address
Apt. No.
City
County
State
Zip Code
Telephone Number
Date of Birth
Gender:
Social Security Number
Female
Male
Ethnicity
Race
Hispanic
Other
White
Unable to Determine
Native Hawaiian/Pacific Islander
Black
Asian
American Indian/Alaskan Native
Driver’s License Number:
State of Issuance:
List any other additional addresses or cities in Texas that you have lived in (continue on back as needed)
SECTION 2: SIGNATURES
This section of the form must be signed by the subject of the background check and not the designee.
•
I am the person listed above in Section 1 of this form. The information in this document is correct and I am a
prospective or current volunteer, employee, or board member of the volunteer organization listed in Section
3. I agree to update the volunteer organization of any changes to the information above.
•
I grant permission to the volunteer organization listed in Section 3 to request a Child Abuse/Neglect Central
Registry and a Texas Department of Public Service Criminal history check as well as any subsequent checks
so long as I am active with that agency.
•
I authorize DFPS to transmit the results of this background check via e-mail and I acknowledge that DFPS
cannot guarantee that information transmitted electronically is secure and accessible only to approved
parties.
•
I understand that the information I am providing will be part of any request and that providing false
information is a violation of Texas Penal Code Section 37.10.
•
I acknowledge that my designee can receive my background check results only as described in Section 5.
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