Form Cca-1211a - Request For Search Of Background Checks
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA- 1211AFORPDF (10-17)
Division of Employment & Rehabilitation Services
Child Care Administration
REQUEST FOR SEARCH OF BACKGROUND CHECKS
This document and any files transmitted with it are confidential and intended solely for the use of the individual or entity to
which they are addressed. If you have received this information in error, please notify the sender and destroy the information.
The information contained in the Central Registry of Arizona Department of Child Safety (ADCS), and any attached files
shall be used as a factor to determine qualifications for individuals applying for contracts with this state, including employees
of the prospective contractor, contractors, and subcontractors for positions that provide direct services to children.
The information contained in the Central Registry and any attached files are confidential and shall not be further
disseminated or shared. SPECIAL NOTE: In order to adhere to confidentiality requirements, this document can
only be completed by either the owner or the individual responsible for hiring staff and volunteers for this facility.
PLEASE FILL OUT THE INFORMATION BELOW. All applicable fields must be completed, accurately and legibly.
PROVIDER or CONTRACTOR NAME
PROVIDER ID
(Assigned by DES)
Licensed Center Number: CDC-
Certified Group Home Number: SGH-
TRACKING NUMBER
(
You must provide your unique tracking number. This number will be used to identify and track this document
:
and the individuals linked to it.)
CCA CONTRACT NUMBER:
SX:
(Assigned by DES)
Check one:
New Contract
New Employee Hire
CCA Certified Home
CCR&R Registered Home
PHONE NUMBER (Including Area Code)
EMAIL ADDRESS (Results will be emailed to this Address)
MAILING ADDRESS (No., Street)
CITY
STATE
ZIP CODE
NAME OF PERSON AUTHORIZED TO SUBMIT REQUEST (Print/Type)
REQUESTOR’S SIGNATURE
DATE OF REQUEST
SUBMIT YOUR COMPLETED REQUEST THROUGH ONE OF THE FOLLOWING METHODS:
Fax to: CCA BACKGROUND CHECKS (602) 542-8436
Email_[secure] to:
CCACentralRegistry@azdes.gov
Results of this check will be:
1. EMAILED to the address above indicating that one or more individuals on the request was (were
unable to be processed with the information provided; or
2. EMAILED to the address above if all names are cleared; or
3. EMAILED to the address above with information on individuals who are found to have a substantiated
finding of child abuse or neglect; and
4. MAILED to the individual who is found to have a substantiated finding that disqualifies him/her from
providing direct services to children.
FOR INTERNAL USE ONLY
DATE OF SEARCH
NUMBER OF NAMES CHECKED
NAME OF PERSON COMPLETING CHECKS
EOE/ADA/LEP/GINA disclosures located on attached Disqualification Acts page
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