Form Soc 834 - Request For Grievance Hearing
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR GRIEVANCE HEARING
REFERRAL NUMBER
COUNTY OF
No grievance hearing shall be required when a court of competent jurisdiction has determined that the suspected
abuse or severe neglect has occurred, or when the allegation of child abuse or severe neglect resulting in the re-
ferral to the Child Abuse Central Index is pending before the court.
A. CONTACT INFORMATION
DATE OF BIRTH
NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE NUMBER:
ALTERNATE NUMBER:
(
)
(
)
I hereby request a grievance hearing to dispute the decision to list my name on the Child Abuse Central Index
(CACI). I acknowledge that I have received a copy of the Notice of Child Abuse Central Index Listing and a copy of
the Grievance Hearing Procedures.
B. REASON FOR GRIEVANCE
The reason I am requesting a grievance hearing is because (YOU MUST CHECK AT LEAST ONE):
I am not the person who committed the alleged act(s) of abuse or severe neglect.
The alleged act(s) of abuse or severe neglect did not occur.
Even if the alleged act(s) occurred, these acts are not abuse or severe neglect within the meaning of the Child Abuse
and Neglect Reporting Act.
Other. If this box is checked, please explain below. If you need more space for your explanation, you may attach
additional pages to this form.
______________________________________________________________________________________________
______________________________________________________________________________________________
SIGNATURE:
DATED:
Check this box if you would like to schedule an appointment so that you can examine all records and evidence related
to investigation of the referral, except for information made otherwise confidential by law. At this appointment, you must
also bring and disclose to the county all records and evidence that support your claim that you should not be listed on
the CACI.
You may have an attorney or other representative present at the hearing to assist you. If you intend to have an attorney
or other representative present, please provide us with the following information.
C. ATTORNEY/REPRESENTATIVE INFORMATION
ATTORNEY OR REPRESENTATIVE’S NAME:
PHONE NUMBER:
(
)
ATTORNEY OR REPRESENTATIVE’S ADDRESS:
Please return this Request for Grievance to this address:
Address:
Attn:
SOC 834 (3/13)
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