Occ 1260 Form - Release Of Information - Child Care

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
RELEASE OF INFORMATION – Child Care
Child Care regulations require signed and notarized permission to examine records of child and adult abuse and neglect for information
about:
1) The applicant/operator (if the applicant/operator is an individual) or family day care provider;
2) Each child care center employee or staff member;
3) Each adult, 18 years old or older, living on the premises of the child care facility or applicant;
4) Each family day care substitute;
5) Each family day care additional adult;
6) Each trustee, manager, and board member, who may have frequent contact with children in care, if the applicant/operator
is a corporation, agency, association, or other organizational entity; and
7) Any other individual identified by the Office.
STATEMENT OF PERMISSION
I hereby authorize the Local Department of Social Services (DSS) to release to the Office of Child Care (OCC) any files or
records of child and adult abuse or neglect in order to help OCC:
• Evaluate my suitability for employment in or by a child care center, or
• Determine whether to approve the issuance or maintenance of an initial or continuing license, letter of compliance or
registration for: ________________________________________________________________________
, located at:
(Name of Applicant/Operator, or Licensed, Letter of Compliance or Registered Child Care Facility)
________________________________________________________________________________________________
Street
Town/City
State
Zip Code
Furthermore, I understand that the information obtained by OCC from the State or Local Department of Social Services may
provide grounds for OCC to:
• Prohibit or require termination of my employment at the child care center, or
• Deny, suspend, or revoke the license, letter of compliance, registration or application of the Child Care Center, Family Child
Care Provider or Applicant/Operator named above.
_________________________________________________________________________ |________________________________
Print Name
First
Middle
Maiden
Last
Other Names Used
__________________________________________________________________________________________________________
Address:
Street
City
State
Zip Code
________________________ ____________________
____________
____________________________________________
Telephone Number
Social Security Number
Date of Birth
Email Address
Male
Female
Primary Language Spoken: __________________
Position____________________________________
Employee, Resident, Substitute, Volunteer, etc.
Race (check all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or
Pacific Islander
White
Other (specify): ____________________
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
If I am not the Applicant/Operator or Provider, I authorize OCC to release this information to an authorized representative of
the Child Care Center, or to the Family Child Care Provider or the Applicant/Operator.
_________________________________________________
Signature
Date
_________________________________________________
Notary Signature
My commission Expires: __________
(for OCC use only)
Background Clearance Findings
Person Conducted Search _________________________Date: __________________
1. T
he individual whose name(s) being searched is NOT identified in the Central Registry as being responsible for abuse or neglect.
2. Based on the information provided by Local Department of Social Services, we have determined that ____________________________ is
listed in the Central Registry as being responsible for an
Indicated/
Unsubstantiated disposition of
Abuse/
Neglect in reference to
an investigation conducted in ________________________________.
3. Summary (181) Received from Local Department of Social Services on_________________________________________________________
OCC 1260 – Revised 11/15 - All previous editions are obsolete.

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