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Dpp-156 - Central Registry Check For Child Care Staff Form - Commonwealth Of Kentucky Cabinet For Health And Family Services Page 2

CENTRAL REGISTRY CHECK

A check or money order made payable to the “Kentucky State Treasurer” in the amount of ten dollars ($10.00)

must accompany your request to process a Child Abuse or Neglect Check. The Child Abuse or Neglect Check will

NOT be processed without payment. Mail check or money order to:

The Cabinet for Health and Family Services

DCBS/Division of Child Care

275 East Main St., 3C-F

Frankfort, Kentucky 40621

I hereby authorize the Cabinet for Health and Family Services to complete a Child Abuse or Neglect check

and provide the results of the check to the employer or agency listed below. I also release the Cabinet for

Health and Family Services, its officers, agents, and employees, from any liability or damages resulting

from the release of this information.

All the information provided is complete and true to the best of my knowledge. I understand if I give false

information or do not report all of the information needed, I may be subject to prosecution for fraud.

_________

Signature of the Individual Submitting to the Child Abuse or Neglect Check

Date

_________

Witness

Date

The individual authorizing a Child Abuse or Neglect check may submit a CHFS-305, Authorization to

Disclose Protected Health Information form, authorizing the Cabinet to disclose additional information

regarding a substantiated finding to the employer or agency listed below should the employer or agency

request additional information pursuant to 922 KAR 1:510, Authorization for disclosure of protection and

permanency records.

NAME OF EMPLOYER/AGENCY:_______________________________________________________

ADDRESS:

______ CITY:

___

STATE:

_______________

ZIP:

PHONE:

_______________

RESULTS OF CHILD ABUSE OR NEGLECT CHECK

[FOR OFFICIAL USE ONLY]

No reportable incident found in accordance with 922 KAR 1:470.

Substantiated child abuse found on the registry

Date of substantiated finding: ____________

Substantiated child neglect found on the registry

Date of substantiated finding: ____________

CHECK CONDUCTED ON _________________BY ________________________________________________________

DPP-156

(R. 02/08)

922 KAR 1:470

Page 2 of 2

Dpp-156 - Central Registry Check For Child Care Staff Form - Commonwealth Of Kentucky Cabinet For Health And Family Services Page 2

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