Professional Type B Child Care Licensing First Contact Packet (Page 4 of 5) in pdf

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Authorization to Release Information to Hamilton County

Please complete all of the information below. The individual completing this form is the: (please check U the one below that applies)

Provider;

Adult Household Member;

Emergency/Substitute Caregiver;

Employee;

Assistant

If you are not the home provider, what is the name of the provider with whom you are associated?

Your Name

Date of Birth

Street Address

PRINT Your Name

Social Security # (Do not put your Tax ID#)

City

State

Zip Code

Notice to Type B Home Providers Concerning Hamilton County’s Initiative to Do Daily Cross Checks of Criminal Arrest Records

The Hamilton County Department of Job and Family Services (HCJFS) and the Hamilton County Clerk of Courts (Clerk’s Office) collaborate on an initiative to

best protect children in Type B Child Care Homes and ensure compliance with state regulations. Effective September 2007, HCJFS will provide names, social

security numbers and dates of birth for providers, their adult household members, Emergency/Substitute (E/S) Caregivers, Assistants and Employees to the

Clerk’s Office. The Clerk’s Office will cross-check the names with records it maintains of criminal charges on a daily basis.

Under Federal law, state and local government agencies are required to provide information to individuals about the agency’s use of the individual’s social

security number. The release of your social security number to HCJFS to run a continuing cross check by the Clerk’s Office is voluntary. Using your social

security number provides the best means of ensuring the Clerk’s cross-check is accurate. Your social security number is confidential. It will not be released as

a public record. Precautions will be taken to maintain the information in a secure manner. All other information is considered a Public Record.

Under Ohio Administrative Code (OAC) Section 5101:2-14-07 (D), the provider must report any investigation by a law enforcement agency to the CDJFS.

Providers, their adult household members, E/S caregivers, Assistants and Employees must comply with 5101:2-14-07 of the OAC, which requires they sign the

“Child Care Convictions Statement” attesting they have never been convicted of or plead guilty to child abuse or other crimes of violence set forth in section

5104.09 or 5104.013 of the Revised code.

The sharing of information between HCJFS and the Clerk’s Office is a means of verifying Type B Provider obligations under the law. This initiative does not

relieve the provider of the responsibility to inform HCJFS of any criminal charges brought against him/her, a resident of their home or their E/S Caregiver.

I have read the above notice, and

CONSENT, or

DO NOT CONSENT to Hamilton County Job and Family Services releasing my name, date of birth,

and social security number to the Hamilton County Clerk of Court’s office for the purpose of doing a daily cross-check of criminal charges.

SIGNATURE : ______________________________________________________ DATE : _______________________________

HCJFS 0170 (REV. 1-14)