Form Scr-1 Lic - State Central Registry Disclosure Form printable pdf download

SCR-1 LIC

STATE OF LOUISIANA

Rev. 01/13

06/11 Issue Obsolete

DEPARTMENT OF CHILDREN AND FAMILY SERVICES

STATE CENTRAL REGISTRY DISCLOSURE FORM

This form must be completed by each individual owner, operator, administrator, current or prospective

employee or volunteer of a child care facility or juvenile detention facility licensed by the Louisiana

Department of Children and Family Services for themselves. Any owner, operator, administrator, current or

prospective employee, or volunteer of a child care facility or juvenile detention facility licensed by the

department who knowingly falsifies the information on the State Central Registry Disclosure Form shall be

guilty of a misdemeanor offense and shall be fined not more than five hundred dollars, or imprisoned for not

more than six months, or both. R.S. 46:1414.1.C or R.S. 15:1110.2(C).

This form shall be maintained by the owner/operator of the licensed facility in accordance with current

licensing standards as mandated by R.S. 46:1414.1.B or R.S. 15:1110.2(B).

Name of Licensed Facility (Print or Type)

Physical Address of Licensed Facility

License #

Name of Individual/Applicant (Print or Type)

Date of Birth

Social Security #

Maiden, Previous or Any Other Name Used

Race

Sex

Current Street Address

City and State

Zip Code

Most Recent Previous Address

City and State

Zip Code

(

)

(

)

(

)

Current Home Phone #

Current Cell Phone #

Work Phone #

My name

is not

currently recorded as a perpetrator on the State Central Registry for what the

(check one)

Department of Children and Family Services (DCFS) has determined to be a justified

(valid) finding of child abuse or neglect.

have

have not

been determined to have a justified (valid) finding of abuse or neglect since the Risk

Evaluation Panel finding.

If the DCFS Licensing Section has reasonable suspicion or is provided with

facts or information that your name is on the State Central Registry as a

perpetrator with a valid/justified finding of abuse and/or neglect, the Licensing

Section may request a clearance of the SCR without your permission. If your

name does in fact appear on the SCR as described above, the department will

notify both your employer (the facility named above) and the appropriate District

Attorney’s office of your failure to comply with R.S. 46:1414.1 or R.S. 15:1110.2.

The information given is true and complete to the best of my knowledge.

Signature

Date

Signature of Licensed Facility Representative

Date

Form Scr-1 Lic - State Central Registry Disclosure Form

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