Get Va Disclosure Statement For Licensed Private Provider Employees 2023-2025

This guide provides step-by-step instructions for effectively completing the VA Disclosure Statement for Licensed Private Provider Employees online. By following this guide, you can ensure that all information is accurately provided, helping facilitate the background investigation required by law.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the document and access it in the editor.
2. Enter the licensed provider business name in the designated field. This is the name under which the provider operates.
3. Input the licensed provider number, which can be a 3 or 4 digit code unique to the provider.
4. Fill in the individual's name using the format of last name, first name, and middle name as applicable.
5. Provide the individual's Social Security number in the corresponding field, or mark 'No SSN #' if not applicable.
6. Complete the individual's mailing address by entering the street, city, state, and zip code.
7. Enter the individual's phone number, ensuring to include the area code.
8. Indicate whether the individual has ever been the subject of a founded complaint of child abuse or neglect, selecting 'Yes' or 'No' and providing details if necessary.
9. Respond to the question regarding any convictions or pending charges for offenses by selecting 'Yes' or 'No', and list all relevant cases if applicable.
10. If applicable, indicate if any misdemeanor assault and battery convictions occurred while employed in a direct consumer care position.
11. Read the certification statement carefully and ensure all concepts are understood before signing.
12. Sign and date the form to confirm all entries are complete and truthful.
13. Save your changes, then download, print, or share the form as needed to complete the submission process.

Complete your documents online for a smooth and efficient filing process.