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SCR-1 LIC Rev. 01/13 06/11 Issue Obsolete STATE OF LOUISIANA 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 - Current Home Phone My name is is not check one I have Current Cell Phone have not Work Phone currently recorded as a perpetrator on the State Central Registry for what the valid finding of child abuse or neglect. 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. 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. 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 - Current Home Phone My name is is not check one I have Current Cell Phone have not Work Phone currently recorded as a perpetrator on the State Central Registry for what the valid finding of child abuse or neglect.