Form Cfs 718-B - Authorization For Background Check For Child Care - The Illinois Dcfs Page 2
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2WHO SHOULD USE THIS FORM: This form must be completed by every person age 13 or older as part of an application to operate or reside in a
child care facility, or be employed by or volunteer at a day care or group day care home. Every person subject to a background check must complete the
first three sections identifying the type of facility and what role they will have at the facility and all personal information. All identifying information
must be accurate and complete. The Parent or Guardian’s signature is required if background check is for a minor.
ADDITIONAL INSTRUCTIONS FOR SECTIONS 2 AND 3 OF THE FRONT PAGE
Name:
Current and all former names used by the individual must be included. If no other names, write “none.”
Social Security,
THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY, INDIVIDUAL
ITIN or Assigned #.
TAXPAYER IDENTIFICATION (ITIN) NUMBER OR DEPARTMENT ASSIGNED NUMBER
Address:
Current and all addresses, including county, where the person has lived in the past five years (Indicate if outside of Illinois)
Race:
Enter all race codes that apply.
NA
=
Native American/Alaskan (Indian or Eskimo)
WH =
White
AO
=
Asian
UK
=
Unknown
BL
=
Black/African American
DI
=
Declined to Identify
PI
=
Native Hawaiian/Pacific Islander
CV
=
Could not be Verified
Ethnicity:
Enter the primary Ethnicity
NH
=
Not Hispanic (NONE)
HA
=
Hispanic Central American
HS
=
Hispanic South American
HN
=
Hispanic Dominican
HM =
Hispanic Mexican
HO
=
Hispanic Other
HP
=
Hispanic Puerto Rican
UK
=
Unknown
HD
=
Hispanic Spanish Descent
DI
=
Declined to Indentify
HC
=
Hispanic Cuban
CV
=
Could not be Verified
ADDITIONAL INSTRUCTIONS FOR SECTIONS 4 OF THE FRONT PAGE
Instruction for Left Side -
Instructions for Right Side –
Name of Facility:
The full name which appears on the license application or the
Supervising Agency:
Print the name and Provider ID# of Agency which
license. (DO NOT USE ACRONYMS)
will supervise the facility
Provider ID #:
Provider ID #:
The Provider ID. (The number which appears on the license
DCFS Region/Site/field:
The DCFS Region/Site/Field.
certificate for the facility. Initial Applications will be assigned #
Name of the
by Background Check Unit.)
Worker:
Name, ID and phone of the worker
Street/City/Zip:
The site of licensed facility where person is licensed or
Name of the
employed.
Supervisor:
Name, ID and phone of the supervisor
The Authorization for Background Check must be submitted to the worker for completion of Section 4 and for forwarding to the DCFS pertinent
Background Check Unit. The worker must check the form for completeness and accuracy, confirm that the person (if age 18 or older) has been
fingerprinted, and verify the correct spelling of names alongside a form of identification, such as a driver’s license or photo ID.
AUTHORIZATION/CERTIFICATION
I authorize the Illinois Department of Children and Family Services to conduct an investigation to determine whether I have ever been
charged with a crime and, if so, the disposition of those charges. I authorize the Department to request information and assistance from
the U.S. Justice Department and the Illinois Department of Law Enforcement in the conduct of this investigation. I authorize the
Department to periodically search child abuse and neglect reports to determine whether I have been a perpetrator of an “indicated”
incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act. The child abuse and neglect background
check and the criminal history investigation may be used for considering an application for license, current or prospective employment,
or service as a volunteer in a child care facility. Persons 13-17 years of age signing this form authorize a search of CANTS and LEADS
only and are not subject to fingerprinting.
I understand that information obtained as a result of my authorizing this investigation is confidential but may be shared with my
employer, prospective employer, the licensing applicant for whom my background check is required or with authorized licensing staff
in accordance with applicable state and federal law and DCFS Regulations. I further certify that the information provided on this form
is true and correct. I acknowledge that falsification of any information provided above and/or the results of the background check may
be full and sufficient grounds to deny the application for licensure or may result in the termination of my employment.
Should you feel that the information on your Illinois State Police record or Federal Bureau of Investigation record is incorrect you may
visit: for the ISP and for FBI.
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