Central Abuse Hotline Record Search Template
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Central Abuse Hotline Record Search
I/we, ________________________________________________ and ________________________________________________
(please print – first, middle, last name)
(please print – spouse first, middle, last name, if applicable)
as an applicant for adoption, an applicant for licensing/registration, or a DCF employee, authorize a search for reports of abuse,
neglect or abandonment investigated pursuant to Chapter 39, Florida Statutes in which my name appears and there were “verified
indicators” of maltreatment of a child(ren). I understand I will be given the opportunity to discuss the findings of the report(s). I
further understand that the central abuse hotline search is only one part of the preliminary report to the court for adoption, one of the
requirements reviewed by an agency with the authority to license or approve homes for the care of develop-mentally disabled
persons and children, including family child care homes and facilities, or for DCF employment. This consent is valid solely for the
requesting agency/facility listed below on this form.
Applicant Signature:____________________________________________ Date:______________ Phone:_________________
Go To Page 2
Spouse Signature:_____________________________________________ Date:______________ Phone:_________________
Applicant: SSN:________________ DOB:______________ Race:____ Sex:____
Spouse: SSN:________________ DOB:______________ Race:____ Sex:____ Prior Name(s):________________________
________________________
Current Address:
Address
City
County
State
Zip
Dates at Address
______________________________________________________________________________________________________
Previous Address:
Address
City
County
State
Zip
Dates at Address
______________________________________________________________________________________________________
Previous Address:
Address
City
County
State
Zip
Dates at Address
______________________________________________________________________________________________________
Reason for Record Search:
Adoption Applicant (Chapter 63)
DCF Employee (Chapter 39)
Licensing/Registration Applicant (Chapters 39, 415, 402 or 409)
(NOTE: Searches of the Central Abuse Hotline may not be used for any employee except those working for DCF.)
Family child care, foster/shelter/group home or adoption applicants must list all child and adult household members on page two of
this form. Do not include any foster care children.
TO BE COMPLETED BY REQUESTING AGENCY
Child Care Center
Family Child Care Home
Foster/Shelter/Small Group Home
Adoption
Child-Caring Agency
Child-Placing Agency
DD Foster/Small Group Home
Go To Page 2
OCA and/or Facility ID:__________________________________
Facility/Agency Name:_____________________________________________________________ Phone:________________
Address:_______________________________________________________________________________________________
Mailing Address
City
Zip Code
I understand it is a misdemeanor of the first degree for any agency to use or release abuse, neglect or abandonment information
to others. The information is CONFIDENTIAL and may be used only for the purpose for which it was obtained.
_____________________________________________________________
________________
Signature of Requesting Facility/Agency Representative
Date
CF 1651, PDF 09/2005
Page 1 of 2
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