Fillable CHILD ABUSE SCREENING REQUEST INFORMATION (State of Georgia)

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CHILD ABUSE SCREENING REQUEST INFORMATION (State of Georgia)

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CHILD ABUSE SCREENING REQUEST INFORMATION
Edited 1-6-16 Keep a copy for your records.
This form is to request a screening to check for Child Protective Services history.
AGENCY REQUESTING SCREENING INFORMATION
NAME & JOB TITLE
TEL #
EMAIL
NAME OF AGENCY
STREET ADDRESS
CITY/STATE/ZIP CODE
SCREENING RESULTS TO BE SENT TO
NAME
TEL #
EMAIL
NAME OF AGENCY
STREET ADDRESS
CITY/STATE/ZIP CODE
INFORMATION ON PERSON TO BE SCREENED (APPLICANT)
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME *If you have been married, you have to provide this
information.
OTHER NAMES USED IN THE PAST
CURRENT STREET ADDRESS
CITY/STATE/ZIP CODE
COUNTY
PREVIOUS ADDREESS
CITY/STATE/ZIP CODE
DATE
PREVIOUS ADDRESS
CITY/STATE/ZIP CODE
DATE
PREVIOUS ADDRESS
CITY/STATE/ZIP CODE
DATE
PREVIOUS ADDRESS
CITY/STATE/ZIP CODE
DATE
DATE OF BITH
SSN#
SEX
CURRENT HOUSEHOLD MEMBERS (To be completed by Foster Care/Adoptions applicants ONLY.
NAME/ALIAS (First, Middle, Last)
DATE OF BIRTH
SSN #
GENDER
PREVIOUS
STATE(S)
DATE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
FEMALE
MALE
IN ORDER TO VERIFY THAT YOU ARE THE REQUESTING AGENCY, PLEASE SUBMIT A WRITTEN REQUEST ON
AGENCY LETTERHEAD ALONG WITH THIS FORM TO THE GEORGIA CHILD PROTECTIVE SERVICES EMAIL
SIGNATURE OF APPLICANT
DATE
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CHILD ABUSE SCREENING REQUEST INFORMATION (State of Georgia)

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Completed 30 November 2021

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