Nevada > Statewide > Division Of Child And Family Services > Adoption
Consent And Release Form For Fingerprinting And Criminal History Review - Nevada
| Consent And Release Form For Fingerprinting And Criminal History Review Form. This is a Nevada form and can be used in Adoption Division Of Child And Family Services Statewide . |
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BRIAN SANDOVAL Governor MICHAEL J. WILLDEN Director RICHARD WHITLEY, MS Administrator TRACEY D. GREEN, MD State Health Officer STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH DIVISION BUREAU OF HEALTH CARE QUALITY AND COMPLIANCE Health Facilities/Lab Services 727 Fairview Dr, Suite E Carson City, Nevada 89701 (775) 684-1030 Fax: (775) 684-1073 Health Facilities/Lab Services 4220 S. Maryland Parkway Suite 810, Building D Las Vegas, NV 89119 (702) 486-6515 Fax: (702 ) 486-6520 Radiation Control 4150 Technology Way Suite 300 Carson City, Nevada 89706 (775) 687-7550 Fax: (775) 687-7552 Radiation Control 2080 E. Flamingo Suite 319 Las Vegas, Nevada 89119 (702) 486-5280 Fax: (702) 486-5024 Child Care Licensing 727 Fairview Dr, Suite E Carson City, Nevada 89701 (775) 684-4463 Fax: (775) 684-4464 CONSENT AND RELEASE FORM FOR FINGERPRINTING AND CRIMINAL HISTORY REVIEW A clearance cannot be issued without this form. You must complete this form when originally hired and when changing facilities, being rehired, or obtaining a new background check. Your original background check should take place in the jurisdiction where you will be employed. A valid child care work card issued by one jurisdiction may be valid in another jurisdiction without another background check (please consult with law enforcement where you will be employed or call the Child Care Licensing). Child Care Licensing requires a new background check every five years. I, , understand that as an employee, applicant, licensee or resident of Child Care Licensing 4180 S. Pecos, Ste 150 Las Vegas, Nevada 89121 (702) 486-7918 Fax: (702) 486-6660 Child Care Licensing 1010 Ruby Vista, Ste 101 Elko, Nevada 89801 (775) 753-1237 Fax: (775) 753-1336 (facility name) a child care facility, I am required to be fingerprinted and to undergo a criminal record review pursuant to NRS 432A.175. NAC 432A.200(4)(a) requires fingerprinting be completed and submitted within 3 working days after date of hire or 3 days of presence in the facility and every 5 years thereafter. I do hereby consent to be fingerprinted and agree to the following conditions and terms: 1. The fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI), the Nevada Criminal History Repository, and the Child Abuse and Neglect System (CANS). 2. I hereby authorize the FBI, Nevada Criminal History Repository, and/or other local law enforcement agencies and Child Protective Services agencies to release criminal history information and CANS history to Child Care Licensing. 3. All information provided to Child Care Licensing is confidential, as relating to a third party or entity. 4. I hereby authorize the Nevada Criminal History Repository to retain a fingerprint card in the central repository's master file for the sole purpose of identifying same against subsequent disqualifying criminal arrest and I authorize the Nevada Criminal History Repository to release criminal history information to Child Care Licensing in accordance with dissemination restrictions as provided for in the Nevada Revised Statutes. 5. I may be suspended, terminated, or disqualified from employment and/or licensure based on the findings of the criminal record review consistent with applicable laws and regulations or on the findings of the Child Abuse and Neglect System. 6. I understand that I may review the challenge the accuracy of any and all criminal history records which are returned to the submitting agency, and that the proper forms and procedures will be furnished to me by the Nevada Department of Public Safety Records Bureau upon request. 7. This waiver and its authority is valid until such time as the applicant is no longer licensed and/or employed at a child care facility. 8. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided information to the submitting agency for any statement(s), omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons, firms, institutions, or agencies providing such information to the State of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free will. Name of Nevada child care facility where you worked previously Last date worked at facility Public Health Working for a Safer and Healthier Nevada American LegalNet, Inc. www.FormsWorkFlow.com Name of child care facility (where applying/employed): Facility address: Street Your name: Last Maiden name, nickname, and other names used: Your position at the above facility is (please check): Cook Driver Resident Volunteer Owner Director First City State Telephone: Zip Code Middle Staff Member (title): Other (position) Do you have any scars, marks or tattoos? (If yes, give location and description.): Social Security Number: Are you a U.S. Citizen? Yes No If not a U.S. citizen, what is your citizenship? Street address: Street Mailing address: Street Home telephone: Eyes: Sex: Hair: Birth date: Height: Weight: Birthplace: City State Cell phone: Race: Zip Code City State Zip Code This form must be complete and accurate. Failure to comply may result in a rejected application. 1. Have you ever had a substantiation (validation) of child abuse and neglect? Yes If yes, explain: Date of charge: 2. Do you have pending charges/warrants against you? Yes If yes, explain: No Dates of charges/warrants: No 3. Check any of the following which apply, past or present (if additional space is needed use the back of this page): Conviction(s): Yes Arrest(s): Charge(s): Citation(s): Yes Yes Yes No No No No Date of conviction: Date of arrest: Date of charge: Date of citation: Reference NRS432.170 Convictions which may prevent employment in child care. List all arrests, including other states, even if the charges were dropped or dismissed. Please attach a separate page if extra space is needed. DATE CHARGE ARRESTING AGENCY CITY/STATE DISPOSITION American LegalNet, Inc. www.FormsWorkFlow.com I do hereby agree to the above stated conditions and terms and certify that the above information is true and correct. Signature: Applicant My signature below indicates that I have reviewed the arrests shown above, if any. Signature: Director/Owner LAW ENFORCEMENT AGENCY: _______________________________
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