Form Dhr/ssa 1279 - Consent For Release Of Information/background Clearance Request
ADVERTISEMENT
1
2State of Maryland-Child Protective Services Program
CONSENT FOR RELEASE OF INFORMATION/BACKGROUND CLEARANCE REQUEST
INSTRUCTIONS
1. Type or print legibly in ink. INCOMPLETE FORMS WILL BE RETURNED.
2. Submit a separate form for each individual whose name is to be searched.
3. Provide proof of identify and sign Part III in the presence of a Notary Public.
4. This form must be notarized.
5. Return the completed form to either:
Local Department of Social Services in the area where you reside
or
Department of Human Resources
In-Home Services
Social Services Administration
311 W. Saratoga Street, Room 553
Baltimore, MD 21201
Part I: PURPOSE OF SEARCH:
(Complete below and the person that this search pertains to must sign the form on the reverse in part III.)
A. RELEASE TO SELF:
1. To determine if I have been found responsible for indicated or unsubstantiated disposition for a child abuse or neglect investigation.
2. To determine if I have any remaining appeal rights
B. RELEASE TO AN AGENCY/INDIVIDUAL RELATED TO:
Foster Parent
School Personnel
Day Care Center
Kinship Care Provider
Institutional Employee
Family Day Care Provider
Adoptive Parent
CASA
Other Employment (Explain
Custody Evaluation
Volunteer
Other (Explain)
1. Requesting Agency Or Individual Name
2. Name Of Agency Representative
3. Address
City
State
Zip
Telephone
C. RELEASE OF SUMMARY OF AGENCY FINDING:
I am aware that I have an indicated disposition following a child abuse or neglect investigation and I authorize the agency to release a summary to the
individual/agency identified in part I as to why I was found responsible.
Part II: TO BE COMPLETED IN FULL, BY INDIVIDUAL WHOSE NAME IS BEING SEARCHED
Last Name
First
Full Middle
Maiden/Birth Name
1. IDENTIFYING
INFORMATION:
Social Security #
Race
Sex
Birthdate
Other Names Used
City
State
Zip
2. CURRENT ADDRESS
3. PRIOR ADDRESS(S) AND DATE(S)
City
State
Zip
Date
(Within The Past 7 Years)
City
State
Zip
Date
4. CURRENT SPOUSE
Last, First, Full Middle
Race
Sex
Birth Date
5. PREVIOUS SPOUSE
Last, First, Full Middle
Race
Sex
Birth Date
6. FULL NAMES OF ALL CHILDREN LIVING WITH YOU
(Also include adult children not living with you. Attach additional paper if needed)
Last, First, Full Middle
Race
Sex
Birth Date
Last, First, Full Middle
Race
Sex
Birth Date
DHR/SSA 1279 10/03
Side 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal