Form Lic 9163 - Request For Live Scan Service - Community Care Licensing Page 4
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4PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et
seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of
Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may
delay the processing of this form and the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires that you complete a
criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department
will create a file concerning your criminal background check that will contain certain documents, including information
that you provide. You have the right to access certain records containing your personal information maintained by the
Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to
provide copies of some of the records in the file to members of the public who ask for them, including newspaper and
television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has
a criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization
that has a licensee, employee, resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
LIC 9163 (12/15)
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