Arizona Department of Health Services
Bureau of Child Care Licensing
CRIMINAL HISTORY AFFIDAVIT
Complete this form immediately upon beginning employment, and at the time of reapplication for a Fingerprint Clearance Card.
(All requested information is required.)
Applicant’s Name (First, Middle, Last)
Social Security Number
Applicant’s Address (#, Street, City, State, Zip)
Birth date
Facility Name
Facility Address (#, Street, City, State, Zip)
OR
CDC/SGH #
Pursuant to A.R.S. § 36-883.02(H), for purposes of this section, “child care personnel” means any employee or volunteer working at a child care facility.
Pursuant to A.R.S. § 36-897.03(I), for purposes of this section, “child care personnel” means all employees of and persons who are eighteen years of age or older and who reside
in a child care group home that is certified by the department.
Pursuant to A.R.S. § 36-883.02(C) and 36-897.03(B), child care personnel shall certify on forms that are provided by the department that:
I have read and am willing to attest to the following in regards to the offenses listed in A.R.S. § 41-1758.07(B)
for centers, (B) and (C) for Group Homes, which can be found at http://www.azleg.gov/ArizonaRevisedStatutes.asp?Title=41:
1. Are you awaiting trial on or have you ever been convicted of or admitted in open court or pursuant to a plea agreement committing any of the
offenses listed in A.R.S. § 41-1758.07(B) for centers, (B) or (C) for Group Homes, in this state or similar offenses in another state or
jurisdiction?
YES NO
2. Are you a parent or guardian of a child adjudicated to be a dependent child as defined in A.R.S. § 8-201? YES NO
3. Have you been denied or had a certificate revoked to operate a child care group home or a license to operate a child care facility in this or any
other state, or have you been denied or had a certificate revoked to work in a child care facility or a child care group home?
YES NO
Have you been denied a certificate to operate a child care group home or a license to operate a child care facility for the care of children in this
state or another state, or had a license to operate a child care facility or a certificate to operate a child care group home revoked for
reasons that relate to the endangerment of the health and safety of children?
YES NO
ALL QUESTIONS MUST BE COMPLETED. Pursuant to A.R.S. § 36-883.02(E), and A.R.S. § 36-897.03(E), the forms are confidential.
Pursuant to A.R.S. § 36-883.02(F), a child care facility shall not allow a person to be employed or volunteer in the facility in any capacity if the
person has been denied a fingerprint clearance card pursuant to section 41-1758.07 or has not received an interim approval from the Board of
Fingerprinting pursuant to A.R.S. § 41-619.55(I).
Good cause exceptions; revocation
I. Pending the outcome of a good cause exception determination, the board or its hearing officer may issue interim approval in accordance with board rule to continue working
to a good cause exception applicant.
Pursuant to A.R.S. § 36-897.03(F), a person who is awaiting trial on or who has been convicted of or who has admitted in open court or pursuant to a plea
agreement to committing a criminal offense listed in Section 41-1758.07, subsection B, paragraph 2 or 3 of this section is prohibited from being employed
in any capacity in a child care group home.
Pursuant to A.R.S. § 36-897.03(G), a person who is awaiting trial on or who has been convicted of or who has admitted in open court or pursuant to a plea
agreement to committing a criminal offense listed in Section 41-1758.07, subsection C shall not work in a child care group home without direct visual
supervision unless the person has applied for and received the required fingerprint clearance card pursuant to §41-1758 and is registered as child care
personnel. A person who is subject to this subsection shall not be employed in any capacity in a child care group home if that person is denied the
required fingerprint clearance card.
Pursuant to A.R.S. § 36-883.02(G) and A.R.S. § 36-897.03(H), the employer shall notify the Department of Public Safety if the employer receives credible
evidence that any child care personnel either:
1. Is arrested for or charged with an offense listed in A.R.S. § 41-1758.07(B).
2. Falsified information on the form required by subsection C for Centers, B for Group Homes, of this section.
________________________________________________________________________________________________________________________
I hereby certify under penalty of perjury that the answers given above are true and correct to the best of my knowledge
and belief.
Applicant’s Signature___________________________________________________________________________ Date ______________________
J:\...\Forms\Criminal History Affidavit (8/09) (update 9-20) CCL form 285
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signature
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41-1758.07. Fingerprint clearance cards; issuance; immunity
B. A person who is subject to registration as a sex offender in this state or any other jurisdiction or who is awaiting trial on or who has been convicted of committing or attempting, soliciting, facilitating or
conspiring to commit one or more of the following offenses in this state or the same or similar offenses in another state or jurisdiction is precluded from receiving a level I fingerprint clearance card:
1. Sexual abuse of a vulnerable adult.
2. Incest.
3. Homicide, including first or second degree murder,
manslaughter and negligent homicide.
4. Sexual assault.
5. Sexual exploitation of a minor.
6. Sexual exploitation of a vulnerable adult.
7. Commercial sexual exploitation of a minor.
8. Commercial sexual exploitation of a vulnerable adult.
9. Child sex trafficking as prescribed in section 13-3212.
10. Child abuse.
11. Felony child neglect.
12. Abuse of a vulnerable adult.
13. Sexual conduct with a minor.
14. Molestation of a child.
15. Molestation of a vulnerable adult.
16. Dangerous crimes against children as defined in section
13-705.
17. Exploitation of minors involving drug offenses.
18. Taking a child for the purpose of prostitution as
prescribed in section 13-3206.
19. Neglect or abuse of a vulnerable adult.
20. Sex trafficking.
21. Sexual abuse.
22. Production, publication, sale, possession and presentation
of obscene items as prescribed in section 13-3502.
23. Furnishing harmful items to minors as prescribed in
section 13-3506.
24. Furnishing harmful items to minors by internet activity as
prescribed in section 13-3506.01.
25. Obscene or indecent telephone communications to minors
for commercial purposes as prescribed in section 13-
3512.
26. Luring a minor for sexual exploitation.
27. Enticement of persons for purposes of prostitution.
28. Procurement by false pretenses of person for purposes
of prostitution.
29. Procuring or placing persons in a house of prostitution.
30. Receiving earnings of a prostitute.
31. Causing one’s spouse to become a prostitute.
32. Detention of persons in a house of prostitution for debt.
33. Keeping or residing in a house of prostitution or
employment in prostitution.
34. Pandering.
35. Transporting persons for the purpose of prostitution,
polygamy and concubinage.
36. Portraying adult as a minor as prescribed in section 13-
3555.
37. Admitting minors to public displays of sexual conduct as
prescribed in section 13-3558.
38. Any felony offense involving contributing to the
delinquency of a minor.
39. Unlawful sale or purchase of children.
40. Child bigamy.
41. Any felony offense involving domestic violence as defined
in section 13-3601 except for a felony offense only
involving criminal damage in an amount of more than two
hundred fifty dollars but less than one thousand dollars
if the offense was committed before the effective date of
this section.
42. Any felony offense in violation of Title 13, Chapter 12 if
committed within five years before the date of applying
for a level I fingerprint clearance card.
43. Felony drug or alcohol related offenses if committed
within five years before the date of applying for a level I
fingerprint clearance card.
44. Felony indecent exposure.
45. Felony public sexual indecency.
46. Terrorism.
47. Any offense involving a violent crime as defined in section
13-901.03.
48. Trafficking of persons for forced labor or services.
C. A person who is awaiting trial on or who has been convicted of committing or attempting, soliciting, facilitating or conspiring to commit one or more of the following offenses in this state or the same or
similar offenses in another state or jurisdiction is precluded from receiving a level I fingerprint clearance card, except that the person may petition the board of fingerprinting for a good cause exception pursuant to section
41-619.55:
1. Any misdemeanor offense in violation of Title 13, chapter12.
2. Misdemeanor indecent exposure.
3. Misdemeanor public sexual indecency.
4. Aggravated criminal damage.
5. Theft.
6. Theft by extortion.
7. Shoplifting.
8. Forgery.
9. Criminal possession of a forgery device.
10. Obtaining a signature by deception.
11. Criminal impersonation.
12. Theft of a credit card or obtaining a credit card by
fraudulent means.
13. Receipt of anything of value obtained by fraudulent use of a
credit card.
14. Forgery of a credit card.
15. Fraudulent use of a credit card.
16. Possession of any machinery, plate or other contrivance or
incomplete credit card.
17. False statement as to financial condition or identity to
obtain a credit card.
18. Fraud by persons authorized to provide goods or services.
19. Credit card transaction record theft.
20. Misconduct involving weapons.
21. Misconduct involving explosives.
22. Depositing explosives.
23. Misconduct involving simulated explosive devices.
24. Concealed weapon violation.
25. Misdemeanor possession and misdemeanor sale of peyote.
26. Felony possession and felony sale of peyote if committed
more than five years before the date of applying for a
level I fingerprint clearance card.
27. Misdemeanor possession and misdemeanor sale of a
vapor-releasing substance containing a toxic substance.
28. Felony possession and felony sale of a vapor-releasing
substance containing a toxic substance if committed
more than five years before the date of applying for a
level I fingerprint clearance card.
29. Misdemeanor sale of precursor chemicals.
30. Felony sale of precursor chemicals if committed more than
five years before the date of applying for a level I
fingerprint clearance card.
31. Misdemeanor possession, misdemeanor use or
misdemeanor sale of marijuana, dangerous drugs or
narcotic drugs.
32. Felony possession, felony use or felony sale of marijuana,
dangerous drugs or narcotic drugs if committed more
than five years before the date of applying for a level I
fingerprint clearance card.
33. Misdemeanor manufacture or misdemeanor distribution of
an imitation controlled substance.
34. Felony manufacture or felony distribution of an imitation
controlled substance if committed more than five years
before the date of applying for a level I fingerprint
clearance card.
35. Misdemeanor manufacture of misdemeanor distribution of
an imitation prescriptiononly drug.
36. Felony manufacture or felony distribution of an imitation
prescription-only drug if committed more than five
years before the date of applying for a level I fingerprint
clearance card.
37. Misdemeanor manufacture or misdemeanor distribution of
an imitation over-the-counter drug.
38. Felony manufacture or felony distribution of an imitation
over-the-counter drug if committed more than five
years before the date of applying for a level I fingerprint
clearance card.
39. Misdemeanor possession or misdemeanor possession with
intent to use an imitation controlled substance.
40. Felony possession or felony possession with intent to use
an imitation controlled substance if committed more
than five years before the date of applying for a level I
fingerprint clearance card.
41. Misdemeanor possession or misdemeanor possession with
intent to use an imitation prescription-only drug.
42. Felony possession or felony possession with intent to use
an imitation prescription-only drug if committed more
than five years before the date of applying for a level I
fingerprint clearance card.
43. Misdemeanor possession or misdemeanor possession with
intent to use an imitation over-the-counter drug.
44. Felony possession or felony possession with intent to use
an imitation over-the-counter drug if committed more
than five years before the date of applying for a level I
fingerprint clearance card.
45. Misdemeanor manufacture of certain substances and
drugs by certain means.
46. Felony manufacture of certain substances and drugs by
certain means if committed more than five years before
the date of applying for a level I fingerprint clearance
card.
47. Adding poison or other harmful substance to food, drink or
medicine.
48. A criminal offense involving criminal trespass under Title
13, Chapter 15.
49. A criminal offense involving burglary under Title 13, Chapter
15.
50. A criminal offense under Title 13, Chapter 23, except
terrorism.
51. Misdemeanor offenses involving child neglect.
52. Misdemeanor offenses involving contributing to the
delinquency of a minor.
53. Misdemeanor offenses involving domestic violence as
defined in section 13-3601.
54. Felony offenses involving domestic violence if the offense
only involved criminal damage in an amount of more
than two hundred fifty dollars but less than one
thousand dollars and the offense was committed before
the effective date of the section.
55. Arson.
56. Felony offenses involving sale, distribution or
transportation of, offer to sell, transport or distribute
or conspiracy to sell, transport or distribute marijuana,
dangerous drugs or narcotic drugs if committed more
than five years before the date of applying for a level I
fingerprint clearance card.
57. Criminal damage.
58. Misappropriation of charter school monies as prescribed in
section 13-1818.
59. Taking identity of another person or entity.
60. Aggravated taking identity of another person or entity.
61. Trafficking in the identity of another person or entity.
62. Cruelty to animals.
63. Prostitution, as prescribed in section 13-3214.
64. Sale or distribution of material harmful to minors through
vending machines as prescribed in section 13-3513.
65. Welfare fraud.
66. Any felony offense in violation of Title 13, Chapter12 if
committed more than five years before the date of
applying for a level I fingerprint clearance card.
67. Kidnapping.
68. Robbery, aggravated robbery or armed robbery.