THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4790 | TTY: 617-660-4606 | FAX: 617-660-5973
STATEWIDE APPLICANT FINGERPRINT IDENTIFICATION SERVICES (SAFIS)
Public School District and Private School SAFIS Results (SAFIS-R) User Designation Form
As part of the Commonwealth of Massachusetts Statewide Applicant Fingerprint Identification Services (SAFIS)
program, the Massachusetts Department of Criminal Justice Information Services (DCJIS) will disseminate state
and national criminal history record check results to public school districts and private schools using the non-
criminal justice results system known as SAFIS Results (SAFIS-R). Each public school district or private school may
have up to two (2) approved SAFIS-R users. Designated users must be approved by the organizations respective
Superintendent, Charter Leader or Private School Director.
Please complete this section for your designated SAFIS-R user.
User 1: ADD CHANGE REMOVE (Select One)
User Full Name (First, MI, Last, Suffix)*:
User Title*:
User E-mail Address*:
User Organization Name*:
User Dept. of Elementary and Secondary Education Organization Code*
,
**:
User Phone Number*:
User Street Address*
,
***:
User City, State, Zip*:
Please complete this section for the approving Superintendent, Charter Leader, or Private School Director.
Full Name*:
Title*:
Signature*:
Date*:
*Required Field.
**If this individual is serving as a SAFIS-R user for more than one organization, please continue to Page 2.
***For public school districts, please list the district address. For private schools, please list the school address.
Please scan and e-mail the completed form to safis@state.ma.us with the email subject line:
SAFIS-R User Designation Form
