Sd Eform - 1050 V2 - Permission To Screen For Reports Of Abuse Or Neglect
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2SD EForm - 1050
V2
HELP
Complete and use the button at the end to print for mailing.
DSS CP-593 10/05
Check box that
Residential Treatment Center
Adoption
Family Day Care Home
corresponds
Independent Living Prep Program
Day Care Center
Group Family Day Care Home
with facility
Group Care Center for Minors
Relative Placement
Before & After School Center
type for this
Child Placement Agency
Head Start Program
License/Registration Application filed
request.
Foster Home
Intensive Residential Tx Ctr.
Also mark corresponding facility type
Shelter Care Facility
Other
PERMISSION TO SCREEN FOR REPORTS OF ABUSE OR NEGLECT
In connection with my application/approval, as a(n) ____________________________________ I understand
that my name must be screened for substantiated reports of abuse or neglect in South Dakota and any other
states in which I have resided since birth. My signature authorizes the South Dakota Department of Social
Services, and any other state, to search any information systems and any central registry for child abuse and
neglect they may have, and review records, identified in the search which may provide information related to
reports and investigations of abuse or neglect. My signature authorizes the release of any information found in
these searches, including but not limited to substantiated incidents not on the central registry of child abuse
and neglect, to the South Dakota Department of Social Services.
Full Legal Name: __________________________________________________________________________
Date of Birth: __________________________Maiden Name:_______________________________________
Other Names Used: ________________________________________________________________________
Social Security #: ________________________Male: ___ Female: ___ Race: _________________________
List All Prior Addresses: (Since birth in chronological order with birthplace first)
Street Address
City
County
State
Dates
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
List Full Name (first, last, birth) and Date of Birth of ALL your OWN Children:
(Do not list other people’s children for whom you might provide daycare)
Name
Date of Birth
Name
Date of Birth
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
The Department of Social Services, it’s staff and agents are released from any and all liability based upon
information transmitted through this authorization, as long as such information is given in good faith.
Signed:_________________________________________________________ Date:____________________
Address:_________________________________________________________________________________
EMPLOYMENT WITH LICENSED/REGISTERED CHILD WELFARE AGENCY
My signature further authorizes the release of any information found in these searches, including but not limited
to substantiated incidents not on the central registry of child abuse and neglect, to the agency listed below.
Agency Name & Phone Number
Agency Mailing Address
Agency License Number
______________________________
_____________________________
_________________________
(_____) ________________
_____________________________
N/A – DSS field office / Head Start
N/A – license not yet issued
CLEAR FORM
1.
PRINT FOR MAILING
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