ATTACHMENT 3 DIRECT SERVICE CENTRAL REGISTRY CLEARANCE FORM.PDF

CSO-1083C
(08/23)
FOR ARIZONA DES USE ONLY
Direct Service  
Central Registry Clearance Form
Position
Date Employed
Contract/Solicitation No. (Required)
Contract/Solicitation No. (Required)
Agency, Please Check Applicable DES Division From Your Agency Supports
Reason for Background Check
Requesting Agency Information
Applicant Subject Information
This form is only to be utilized by agencies contracted to supply AZDES divisions letter security sited below
Applicant/Employee: You are being provided this form because you have applied for a position that requires a search of the Arizona Department of Child Safety 
(DCS) Child Abuse and Neglect Records (CPS/CR) required by Arizona State Law. Your information, upon submission by your employer, will be searched through 
the DCS Central Registry for Employment. All information on this form must be typed or printed. Any form that is missing information or containing information 
that is not legible will be returned to the requesting agency. 
Employers: Return the completed form via secured email to DESCANRegistryChecks@azdcs.gov within 5 business days of hire. For the email subject line, please 
type your DES Division, and the Last Name, First Name of the person the search is conducted for. Example DDD Jones, Jane. One form per email. This form must 
remain confidential in the employee’s file, and it is subject to audit. 
City
State
ZIP
Division of Developmental Disability (DDD)
New Hire
Division of Community Assistance and  Development (DCAD)
Rehire
Division of Child Care  (DCC)
Volunteer
Office of Procurement (OP)
Division of Adult and Aging Services (DAAS)
Annual
Division of Employment Rehabilitation Services (DERS)
Division of Arizona Early Intervention Program (AZEIP)
Title
Middle Name/Initial
Middle Name/Initial
Middle Name/Initial
Date of Birth
Soc. Sec. No.
Agency/Vendor Name
Representative Name
Phone No.
Last Name
Last Name
Last Name
Fax No.
First Name
First Name
First Name
Maiden Name
Email (Required for Results)
Mailing Address
Previous Names, AKAs or Aliases
Current Address
Street Address
Street Address
Street Address
Street Address
City
City
City
City
State
State
State
State
ZIP
Applicant/Employee Email Address (Required)
ZIP
Date From
Date To
ZIP
Date From
Date To
ZIP
Date From
Date To
Yes
No
Have you lived at your current address for five (5) years or longer?
If no, five (5) years of residence history

CSO-1083C
(08/23)
Page 2
Applicant Subject Information ~ continued
Statement of Certification By Applicant/Employee
For Arizona DCS Central Registry Use Only
Yes
Yes
No
No
Are you currently the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction?
If you wish to provide additional information please use space provided or attach additional documentation.
By signing this form, I allow the Department of Child of Safety to report final findings of any DCS child abuse investigation for the Agency listed above. I 
attest under penalty of perjury, that the information provided is true, correct and complete to the best of my knowledge and belief. I further understand the 
provision of false information or intentional misrepresentation of information on this form may result in disciplinary action. Do not type Signatures!
What was the allegation(s)?
When was the investigation(s)?
Where was the investigation(s)?
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?
If yes:
Applicant/Employee Signature (Pen or Digital Signatures with digital verification)
Name of Staff Completing Search (Please Type)
Name of Staff Completing Search Signature
Date
Date Checked
Central Registry Results:
No Record Found
Intake 
No.
Allegation 
Code
Allegation  
Description
Cent. Reg. Exception Approved 
(ONLY applies to Disqualifying Act results)
Central Reg. 
Exception Date
Yes 
No
Disqualifying
Disqualifying
Disqualifying
Non-Disqualifying
Non-Disqualifying
Non-Disqualifying
Non-Disqualifying
Non-Disqualifying
Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, 
programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, 
or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to 
allow a person with a disability to take part in a program, service, or activity are available upon request. 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 DCS services is available upon request. Ayuda gratuita con traducciones 
relacionadas con los servicios del DCS esta disponible a solicitud del cliente.
Request Received Date
SIGN
SIGN