CENTRAL REGISTRY REQUEST FBU-1002A.PDF

FBU-1002A FORFF (2-17)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Employment & Rehabilitation Services
REQUEST FOR SEARCH OF CENTRAL REGISTRY  
FOR BACKGROUND CHECK
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 Arizona Department of Child Safety (ADCS), CHILDS Central Registry 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 or vulnerable adults.  The information contained in the Central Registry for Background Check and any 
attached files is confidential and shall not be further disseminated or shared.
PLEASE FILL OUT THE INFORMATION BELOW. All fields must be completed, accurately and legibly.
Offeror, Contractor, or Subcontractor Name (Print/Type)
Solicitation or Contract Number:
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.):
Check One:
New Contract
Contract Extension
New employee hire
Phone Number
Email Address
Mailing Address
Name of Person Authorized to Submit Request (Print/Type)
Requester’s Signature
Date of Request
DERS Program
Contract Unit Contact Person
SUBMIT YOUR COMPLETED CENTRAL REGISTRY REQUEST THROUGH ONE OF THE FOLLOWING METHODS:
Fax to: DERS CENTRAL REGISTRY REQUEST (602) 542-8436
Email_[secure] to DERSCentralRegistryChecks@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 on the Central Registry; and
4.	 MAILED to the individual who is found to have a substantiated finding on the Central Registry that disqualifies him/her 
from providing direct services to children or vulnerable adult clients of ADES.
Internal Use Only:
For Solicitations Only:  DES Designated Staff (Office of Procurement):  
For Contracts:  Notify DES Designated Staff (Program): 
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. To request this document 
in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language 
assistance for DES services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DES está 
disponible a solicitud del cliente.
Maricopa County
DI21-002283
I
WIOA Title I Employment Services
Mark Monroe

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)]  
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports: 
Yes 
Number: 
[See attached document(s)] 
No 
 Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports
Yes
 Number:
[See attached document(s)]
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
 Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number: 
[See attached document(s)]  
No
 Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
 Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports: 
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)]
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)]
No
 Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

REQUEST FOR SEARCH OF CENTRAL REGISTRY FOR BACKGROUND CHECK
 (All fields must be completed, accurately and legibly.)
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes 
Number:
[See attached document(s)]
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE
INDIVIDUAL’S INFORMATION
NAME
ALIAS [Previously used name(s)]
SOC. SEC. NO.
DATE OF BIRTH
ADDRESS (No., Street, City, State, ZIP Code)
DES – INTERNAL USE ONLY (Search results)
Reports:
Yes
Number:
[See attached document(s)] 
No
Date of Search:
NAME OF PERSON COMPLETING SEARCH
SIGNATURE

DISQUALIFICATION ACTS
A person is disqualified from providing services to DES clients in a direct service position if he/she is identified as the subject 
of the substantiated report for any of the following.
24 Child death due to alleged abuse or neglect, or suspicious death
25 Injuries requiring emergency medical treatment
27 Child age 24 months is shaken (shaken baby syndrome)
33 Untreated life threatening condition, Infant Doe, Non-organic FTT
37 Imminent harm to child under the age of six (6) due to lack of supervision by parent/caretaker
38 Neglect results in injury/illness requiring emergency medical treatment
39 Imminent harm to child due to health or safety hazards in living environment/exposure to the elements
40 Child diagnosed as suicidal by mental health professions, parent refused to allow treatment
41 Physical evidence of sexual abuse reported by a medical doctor or child reporting sexual abuse within the past seven days
42 Child reporting vaginal or anal penetration or oral sexual contact within past 72 hours and has not been examined
43 Abandoned, no parent willing to provide immediate care for a child and child is with a caregiver unable or unwilling to provide care now
45 Injuries may require medical treatment
46 P3 Injury to child under age six years
50 Living environment presents health or safety hazards to a child under the age of six
51 Sexual conduct/physical injury between children due to inadequate supervision
54 Sexual behavior within the past 8-14 days
55 Child diagnosed by mental health professional with behavior consistent with emotional abuse
56 Abandoned, no parent willing to care for a child, child with caretaker unable or unwilling to care for child less than one week
66 Significant developmental delays due to neglect
69 Attempted sexual behavior or sexual behavior, 14 days to three years r last occur unknown
72 Parent, guardian or custodian suggests or entices child to engage in sexual behavior, no touching
76 Use of child by parent, guardian or custodian for material gain
82 Parent, guardian or custodian sexually abused a child in past, now in home with a child
83 Attempted sexual behavior or sexual behavioral when last occurred more than three years
101 Death of a child due to neglect
111 Death of a child due to physical abuse or suspicious death
201 Physical abuse high risk
202 Physical abuse moderate risk
301 Neglect, high risk
302 Neglect, moderate risk
401 Sexual abuse, high risk
402 Sexual abuse, moderate risk
403 Sexual Abuse, low risk
404 Sexual Abuse, response 4
501 Emotion Abuse, high risk
502 Emotional abuse, moderate risk