Get Louisanna Central Registry

SCR 1 Issued 01/10 STATE OF LOUISIANA DEPARTMENT OF SOCIAL SERVICES STATE CENTRAL REGISTRY DISCLOSURE FORM 1/10version This form must be completed by each individual owner operator current or prospective employee or volunteer of a child care facility licensed by the Louisiana Department of Social Services for themselves. Any owner operator current or prospective employee or volunteer of a child care 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 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. Name of Licensed Facility Print or Type License Number and Physical Address print or Type Date Signed Form Received Home Ph. Cell Ph. Name of Individual or Applicant Print or Type Street Address My name is Date of Birth is not check one Social Security Number City and State Zip Code currently recorded as a perpetrator on the State Central Registry for what the Department of Social Services has determined to be a justified valid finding of child abuse or neglect. If it is determined that I do pose a risk to children I am prohibited from requesting another risk evaluation assessment for 24 months from the date of this notice. The information given is true and complete to the best of my knowledge. Signature Date Signature of Licensed Facility Representative DSS Office Use Only Name of Regional Administrator or designee Date State Central Registry Check Completed Date Reviewed Date of notification of results to Child Residential Licensing or Child Care Licensing. R*S* 46 1414. 1. 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. Name of Licensed Facility Print or Type License Number and Physical Address print or Type Date Signed Form Received Home Ph. 1. B. Name of Licensed Facility Print or Type License Number and Physical Address print or Type Date Signed Form Received Home Ph. Cell Ph. Name of Individual or Applicant Print or Type Street Address My name is Date of Birth is not check one Social Security Number City and State Zip Code currently recorded as a perpetrator on the State Central Registry for what the Department of Social Services has determined to be a justified valid finding of child abuse or neglect. Cell Ph. Name of Individual or Applicant Print or Type Street Address My name is Date of Birth is not check one Social Security Number City and State Zip Code currently recorded as a perpetrator on the State Central Registry for what the Department of Social Services has determined to be a justified valid finding of child abuse or neglect. If it is determined that I do pose a risk to children I am prohibited from requesting another risk evaluation assessment for 24 months from the date of this notice.