Fillable CONSENT FOR RELEASE OF INFORMATION REQUES T CPS (State of Maryland)

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CONSENT FOR RELEASE OF INFORMATION REQUES T CPS (State of Maryland)

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DHR/SSA 1279A Side 1 (03/2017 edition) (All other versions are obsolete)
State of Maryland-Child Protective Services Program
CONSENT FOR RELEASE OF INFORMATION
CPS BACKGROUND/ADAM WALSH BACKGROUND CLEARANCE
REQUES
T
*****PLEASE COMPLETE THIS FORM ON LINE AND THEN PRINT *****
Part I: PURPOSE OF SEARCH
A. RELEASE TO SELF:
1. To determine if I have been found responsible for an “indicated” or “unsubstantiated” disposition for a child abuse or neglect
investigation.
2. To determine if I have any remaining appeal rights.
B. RELEASE TO AN AGENCY/INDIVIDUAL RELATED TO:
Adoption School Personnel Day Care Center Youth Camp Personnel Administrator
Foster Care Institutional Employee Family Day Care Youth Camp Worker/Volunteer
Kinship Care CASA Community Mgmt. Entity Other (Specify)
International A
doption Custody Evaluation Group Home/Residential Treatment Facility
Agency/Individual Name Name of Agency Representative
Agency Address (To include street # and name, unit type and #, city, state and zip code) Representative’s Phone Number
- - x
Representative’s Email
Part II: SEARCH INFORMATION (To be completed in full by individual whose name is being searched)
APPLICANT’S LAST NAME FIRST NAME MIDDLE NAME (Full) MAIDEN/BIRTH NAME
SOCIAL SECURITY NUMBER DATE OF BIRTH SEX RACE
-
-
Male Female
OTHER NAMES USED
NUMBER STREET NAME UNIT TYPE/# CITY STATE ZIP CODE COUNTRY
DA
YTIME TELEPHONE NUMBER EMAIL ADDRESS
CURRENT SPOUSE
LAST NAME FIRST NAME MIDDLE NAME (Full) DATE OF BIRTH
FULL NAMES OF ALL CHILDREN (To include adult children and children not residing with you)
LAST NAME
FIRST NAME
MIDDLE NAME (Full)
DATE OF BIRTH
If more than 3 children, attach additional paper if necessary.
Have you lived in Maryland in the past? Yes No Have you worked or volunteered in Maryland in the past? Yes No
If yes to either question, from what years:
DHR/SSA 1279A Side 2 (03/2017 edition) (All other versions are obsolete)
PRIOR ADDRESSES (List all within the past 7 years in Maryland.)
NUMBER
STREET NAME
CITY
STATE
ZIP CODE
DATE
Part III: AUTHORIZATION
Pursuant to Code of Maryland Regulations § 07.02.07, pertaining to the confidentiality of Child Protective Services
investigations and reports, I hereby authorize the Maryland Department of Human Resources (DHR) to notify
(agency or individual as listed in Part I) as to whether a local department of social
services has identified me as responsible for “indicated” child abuse or neglect in any record maintained by the
Maryland Department of Human Resources, any local department of social services, and Child Protective Services.
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PART IV: SIGNATURE (If Applicant is under age 16, must be signed by Applicant’s parent/guardian) DATE
(Print name of signature above)
PART V: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC
City/County
of:
State
of:
Acknowledged before me this day of , 20 _ .
NOTARY PUBLIC
My commission expires: .
DHR/SSA 1279A Side 3 (03/2017 edition) (All other versions are obsolete)
PART VI: BACKGROUND CLEARANCE FINDINGS (for Local Department or DHR use only)
Applicant’s Name:
MD CHESSIE ID#:
1. Active investigation
2. Sent to DHR or Local Department of Social Services: Name:
Date:
3. We have determined that is listed in the state’s database as being
responsible for an Indicated / Unsubstantiated disposition of Abuse / Neglect in reference to an
investigation conducted in
by . Child Protective Service
Investigation #:
. (Unsubstantiated findings may only be released to the MSDE Office of Child Care.)
4. Holding for appeal
5. Notification sent to Applicant on
6. As of this date, the individual whose name was being searched is NOT identified in the state’s
system.
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CONSENT FOR RELEASE OF INFORMATION REQUES T CPS (State of Maryland)

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Completed 15 September 2020

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