Dpp-156 - Central Registry Check For Child Care Staff Form - Commonwealth Of Kentucky Cabinet For Health And Family Services
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2DPP-156
COMMONWEALTH OF KENTUCKY
(R. 02/08)
CABINET FOR HEALTH AND FAMILY SERVICES
922 KAR 1:470
Department for Community Based Services
Division of Protection and Permanency
CENTRAL REGISTRY CHECK
FOR THE FOLLOWING TYPES OF EMPLOYMENT, STATE LAW OR KENTUCKY ADMINISTRATIVE
REGULATIONS REQUIRE A CHILD ABUSE/NEGLECT (CAN) CHECK AS A CONDITION OF
EMPLOYMENT. KENTUCKY ADMINISTRATIVE REGULATIONS MAY BE FOUND ON THE
INTERNET AT PLEASE CHECK THE CATEGORY LISTED BELOW
THAT APPLIES TO YOU FOR WHICH THE CHILD ABUSE OR NEGLECT CHECK IS BEING
REQUESTED:
Day Care Related Categories
Day Care Center Employee or Volunteer
(Required by 922 KAR 2:090)
Applicant for Day Care Center Licensure
(Required by 922 KAR 2:090)
Registered Child Care Provider Applicant
(Required by 922 KAR 2:180)
Other Categories
Foster/Adoption/Independent Living Agency Employee
(Required by 922 KAR 1:310)
Residential Child-Caring Facility Employee
(Required by 922 KAR 1:300)
(Institution/Group Home/Emergency/Wilderness)
IMPACT-PLUS Subcontractor
(Required by 907 KAR 3:030)
Supports for Community Living (SCL) Employee
(Required by 907 KAR 1:145)
Other (If none of the above categories is applicable, please explain the reason for requesting a child abuse or neglect
check, including the statutory or regulatory authority for the request):
_______________________________________________________________________________________
PERSONAL INFORMATION REGARDING THE INDIVIDUAL SUBMITTING TO A CHILD ABUSE OR
NEGLECT CHECK (Please print and submit identifying information such as a copy of your driver’s license, social
security card, or birth certificate):
NAME: ______________________________________________________________________________________
(first)
(middle)
(maiden/nickname)
(last)
Sex: ___ Race: _________ Date of Birth: _________________Social Security #:__________________________
Date of Initial Hire: _______________________
Present Address: _______________________________________________________________________________
City
State
Zip Code
Previous Address: _____________________________________________________________________________
City
State
Zip Code
Previous Address: _____________________________________________________________________________
City
State
Zip Code
Previous Address: _____________________________________________________________________________
City
State
Zip Code
Previous Address: _____________________________________________________________________________
City
State
Zip Code
Please list your addresses for the last five years. Use another sheet of paper, if necessary.
An Equal Opportunity Employer M/F/D
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