Form Pps 10400 - Adult Abuse, Neglect, Exploitation Central Registry Release Of Information
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1
2
3STATE OF KANSAS
ADULT ABUSE, NEGLECT, EXPLOITATION
PPS 10400
CENTRAL REGISTRY
Department for Children and Families
REV 7/15
RELEASE OF INFORMATION
Prevention and Protection Services
I,
, give permission for the release of information concerning
(PRINT ONLY)
myself in the Adult Abuse, Neglect, Exploitation Central Registry to:
Chris Noe
785-506-8652
Contact Person(s)*
Phone
TARC,Inc.
Agency name
2701 S W Randolph Ave Topeka KS 66611
Agency mailing address
Check box if agency is a CDDO, CMHC, or ILRC
Maiden Name and/or Other Names Known By:
(PRINT ONLY)
Address:
Street
City
State
Zip Code
-
DOB:
SS#:
-
Sex: M or F
/
/
(mm/dd/yyyy)
(circle one)
I understand that all information released will be for the exclusive and confidential use of the above named
organization/person. I have read and understand this form and the information provided is true and correct to the best of my
knowledge.
I give permission for the release of any information concerning myself in the Adult Abuse and Neglect Central Registry each
year while I am employed or associated with the above agency.
Yes
No
Signature:
Date:
/
/
(mm/dd/yyyy)
Per statute 65-6205: Community Service Providers, Mental Health Centers and Independent Living Centers may request information for the purpose
of obtaining background information on applicants for employment without signed consent. Signature is not required from the individual for which
the inquiry is made.
RETURN TO:
Adult Abuse Registry
555 S. Kansas Ave
Topeka, Kansas 66603-3444
FOR PPS ADMINISTRATION USE ONLY:
Record found?
Fiduciary
Yes
No
If yes, finding:
Abuse
Neglect
Exploitation
Abuse
(check all that apply)
“Yes” indicates the individual is listed on the adult abuse, neglect, exploitation registry.
Perpetrator’s Name:
Region:
Date Substantiated:
Initial:
Date:
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