Direct Service Position Form - Arizona Department Of Economic Security printable pdf download

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

DIRECT SERVICE POSITION

You are being provided this form because you have applied for a position that provides direct services to children or

vulnerable adult clients of the Arizona Department of Economic Security (ADES). Arizona state law requires all individuals

who provide direct services to children or vulnerable adults to certify whether an allegation of abuse or neglect was made

against them and was substantiated. Your information, upon submission by the employer, will be searched through the ADES

Child Protective Services (CPS) Central Registry. All information contained on this form is confidential.

NAME (Last, First, M.I.)

SOC. SEC. NO.

ALIASES (Such as maiden, nick names, etc.)

DATE OF BIRTH

ADDRESS (No., Street, City, State, ZIP)

Are you currently the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction?

Yes

Have you ever been the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction that resulted in

a substantiated (determined to have occurred) finding?

Yes

If Yes, to the question immediately above:

What was the allegation(s)?

When was the investigation(s) conducted?

Where was the investigation(s) conducted?

If you wish to provide additional information see Direct Service Position Supplement

STATEMENT OF CERTIFICATION

By signing this form, I certify that the information provided is true, correct, and complete to the best of my knowledge and belief.

SIGNATURE

DATE

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the

Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of

1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008, the Department prohibits discrimination in

admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,

genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in

a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for

people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any

other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes

to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability,

please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further

information about this policy, contact 602-771-2870; TTY/TDD Services: 7-1-1. Free language assistance for DES services is

available upon request.

Employers: Please maintain this form as confidential.

Direct Service Position Form - Arizona Department Of Economic Security