Ddd-1727a - Direct Service Position - Arizona Department Of Economic Security printable pdf download

DDD-1727A FORFF (11-15)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

DIRECT SERVICE POSITION

You have applied for a position that provides direct services to children or vulnerable adults. Arizona Revised Statutes

(ARS §

8-804.I) require you to certify, under penalty of perjury, whether an allegation of abuse or neglect was made

against you and was substantiated. If your certification does not indicate a current investigation or a substantiated report of

abuse or neglect, your employer may permit you to provide direct services pending the findings of a Central Registry

Background Check by the Division of Developmental Disabilities. Your employer is required to keep this form and all

information provided on it as confidential.

NAME (Last, First, M.I.)

SOC. SEC. NO.

ALIASES (Maiden, nicknames, etc.)

DATE OF BIRTH

ADDRESS (No., Street, City, State, ZIP)

Are you currently the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction?

Yes

Have you ever been the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction

that resulted in a substantiated (determined to have occurred) finding?

Yes

If Yes, to the question immediately above:

What was the allegation(s)?

When was the investigation(s) conducted?

Where was the investigation(s) conducted?

If you wish to provide additional information see Direct Service Position Supplement

STATEMENT OF CERTIFICATION

By signing this form, I certify that the information provided is true, correct, and complete to the best of my knowledge

and belief.

SIGNATURE

DATE

Employers: Please maintain this form as confidential.

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans

with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II

of the Genetic Information Nondiscrimination Act (GINA) of 2008, the Department prohibits discrimination in admissions,

programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and

retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program,

service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are

deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable

action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If

you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know

of your disability needs in advance if at all possible. To request this document in alternative format or for further information about

this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. •

Disponible en español en línea o en la oficina local.

Ddd-1727a - Direct Service Position - Arizona Department Of Economic Security