Form Dhr/ssa 1279 - Consent For Release Of Information/background Clearance Request (Page 2 of 2) in pdf

Part III: AUTHORIZATION

(Check either 1 or 2 below. )

Pursuant to Maryland Code of Regulation Section 07.02.07.19, pertaining to the confidentiality of Child Protective Services records and

reports, I hereby authorize the Maryland Department of Human Resources (DHR):

1. To notify _______________________________ (self, agency, or individual listed in part I) as to whether a local department of

DHMH - CHHCS

social services has identified me as responsible for “indicated” child abuse or neglect in any record maintained by the

Maryland DHR, any Local Department of Social Services, and Child Protective Services.

2. To release a summary of the indicated finding to _____________________________(self, agency, or individual listed in part I).

DHMH - CHHCS

SIGNATURE

DATE:

: This form must sign in the presence of a Notary Public by the person named in part II.

Part IV. CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC

City/County of: _______________________________________________

State of: _______________________________

Acknowledged before me this ____________________________ Day of _______________________ 20____

Notary Public

My Commission expires: ______________________

Part V. BACKGROUND CLEARANCE FINDINGS (for Local Department or DHR use only)

1. We are unable to determine at this time if the individual for whom a search has been requested has a CPS finding. Form returned to requesting

agency. Date ____________

2. Sent to DHR or Local Department of Social Services:

Name ______________________________________________

Date ________________

Date returned from Local Department _______________________

3. Based on information provided by Local Departments 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 ______________________________. Child Protective Service Case/File/Referral #: ___________________________.

4. Holding for Appeal

Appeal Date ___________________________ Appeal Disposition __________________________________

5. Notification sent to Requesting Agency/Individual: Date______________________________

6. Notification sent to Person: Date______________________________

7. Summary Provided: Date __________________________________

8. As of this date, the individual whose name was being searched is NOT identified in the Central Registry as being responsible for abuse or neglect.

DHR/SSA 1279 10/03

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Form Dhr/ssa 1279 - Consent For Release Of Information/background Clearance Request Page 2