Osah Form 1 - Child Abuse Registry - Dhs, Division Of Family & Children Services
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1OSAH FORM 1
OSAH USE ONLY
AGENCY
CASE TYPE
DOCKET NUMBER
COUNTY
JUDGE
DOCKET NUMBER:
DFCS
DHS, DIVISION OF FAMILY & CHILDREN SERVICES
CHILD ABUSE REGISTRY
County Where Alleged Abuse Occurred:
Agency Reference (SHINES) Number:
Date Notice of Inclusion Was Mailed to Alleged Abuser:
Date Request for Hearing Was Received by DFCS:
Check Only One:
CAR (Child Abuse Registry – Appeal of Notice of Inclusion)
XPUCAR (Request for Expungement from Registry)
ALLEGED CHILD ABUSER
NAME:
TEL #:
DATE REQUEST FOR HEARING WAS
SENT TO OSAH:
CURRENT ADDRESS INCLUDING ZIP CODE:
EMAIL:
ROLE OF ALLEGED CHILD ABUSER:
LEGAL PARENT/GUARDIAN
FOSTER PARENT
OTHER _________________
CLASSIFICATION OF THE CHILD ABUSE (SEE O.C.G.A. § 49-5-182(4)):
AGE OF ALLEGED CHILD
AGE(S) OF CHILD(REN) ALLEGED TO
ABUSER:
HAVE BEEN ABUSED:
(IF UNDER 18) NAME OF PARENT, GUARDIAN, OR LEGAL CUSTODIAN:
TEL #:
EMAIL:
CURRENT ADDRESS INCLUDING ZIP CODE:
RELATIONSHIP TO ALLEGED CHILD ABUSER:
ATTORNEY FOR ALLEGED CHILD ABUSER (IF APPLICABLE)
NAME:
TEL#:
FAX #:
ADDRESS INCLUDING ZIP CODE:
GEORGIA BAR #:
EMAIL:
DFCS OFFICE IN COUNTY WHERE ALLEGED ABUSE OCCURRED
NAME OF OFFICE:
TEL #:
FAX #:
COUNTY DIRECTOR:
TEL #:
EMAIL:
CASEWORKER’S FULL NAME:
SUPERVISOR’S FULL NAME:
ADDRESS INCLUDING ZIP CODE:
SUPERVISOR’S DIRECT TEL #:
CASEWORKER DIRECT TEL #:
EMAIL:
EMAIL:
CPSIS STAFF NAME:
TEL #:
FAX #:
ADDRESS INCLUDING ZIP CODE:
POSITION:
EMAIL:
SPECIAL ASSISTANT ATTORNEY GENERAL (SAAG)
NAME:
TEL#:
FAX #:
ADDRESS INCLUDING ZIP CODE:
GEORGIA BAR #:
EMAIL:
***COPIES OF NOTICE OF INCLUSION AND HEARING REQUEST MUST BE ATTACHED***
This form is available online at
or by telephone request at (404) 657-2800.
(OSAH Rev 08/2016)
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