ALABAMA DEPARTMENT OF HUMAN RESOURCES
CHILD ABUSE / NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE
PRINT OR TYPE in black or blue ink. Additional information regarding the CA/N Central Registry is on the back of this form.
** See instructions
for the address to use when submitting this form. **
Requesting Person or Agency/Organization
Check All That Apply
Mailing Address Child Placing Agency
Residential Child Care Facility
Child Day / Night Care Center
Telephone Number ( ) Email:
Family Day / Night Care Home
PRINT Requestor’s Name Exempt Child Day Care Center
Requestor
Signature
Date Medicaid Rehab. Provider
DHR Vendor
Witness
Signature
Date Other (Please Specify)
_________________________________
The person whose name and identifying information, printed or typed below, will provide unsupervised care and
supervision of children
as an employee volunteer other. This person’s specific job/role is or will be:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name _____________________________________________
Last First Middle
Sex Male
Female
Race ___________ DOB ___/___/______
Current Mailing Address __________________________________________________________________________
Alias, Maiden & Prior Married Name(s) ______________________________________________________________
Name & DOB of Spouse & Former Spouse(s) _________________________________________________________
Name & DOB of Children / Stepchildren ______________________________________________________________
Alabama counties where person has lived and/or worked _________________________________________________
Attach additional pages as needed to provide all information requested above.
To be completed by person being cleared
I authorize the Alabama Department of Human Resources to release information contained in the Child Abuse / Neglect Central
Registry about me to the above named person/agency/organization. I hereby waive any right to any review or hearing to which I may
otherwise be entitled. I further release the Department of Human Resources, its officers, and employees from any and all claims
arising out of or in any way connected to the release or dissemination of any information concerning me.
_________________________________
Signature
________________
Date
_________________________________
Signature of Witness
________________
Date
To be completed by DHR
A search of the Alabama Child Abuse / Neglect Central Registry has been completed with the information provided to
determine if the person identified above has been named as being responsible for child abuse or neglect in Alabama.
DHR releases only
that information which is necessary to discover or prevent child abuse / neglect.
Substantiated report (i.e., indicated) located. See attached information.
Type Report:
Physical Abuse Neglect Sexual Abuse Mental Abuse / Neglect
No report located.
Request Denied ______________________________________________________________________________
Other _________________________________________________________________________________________
_________________________________________________________
Office of Child Protective Services
______________________________________
Date Completed
DHR-FCS-1598 (Revised December 2009)
