Fillable Early Childhood Education Authorization Release Child Dependent Adult Abuse Information (Indian Hills Community College)

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Early Childhood Education Authorization Release Child Dependent Adult Abuse Information (Indian Hills Community College)

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470-3301 (Rev. 2/16) Copy 1: Central Registry Copy 2: Returned to Requester
Iowa Department of Human Services
Authorization for Release of Child and Dependent Adult Abuse Information
This form must be used to authorize release of child or dependent adult abuse information when the person requesting the
information does not have independent access to it under Iowa law. Complete a separate form for each person for whom
information is requested and email to dhsabuseregistry@dhs.state.ia.us
, or fax to (515) 564-4112, or mail to the Iowa
Department of Human Services, Central Abuse Registry, P.O. Box 4826, Des Moines, IA 50305.
Please specify which abuse registry you are requesting by checking the appropriate box below:
Child Abuse Registry Dependent Adult Abuse Registry Both
Please specify your preferred method of response by checking a box and completing the information in Section 1.
Address Fax Email
Section 1: To be completed by the person or agency requesting the information.
Requester: Last
First
Agency Name
Telephone Number
( )
Address
Fax Number
( )
City
Zip Code
Email
List the name and address of the person whose information is being requested:
Name (last, first, middle)
Birth Date
Social Security Number
Address
City
County
State
Zip Code
List maiden name, previous married names, and any alias:
What is the purpose of your request for child or dependent adult abuse information?
I have read and understand the legal provisions for handling child and dependent adult abuse information which is printed
on the second page of this form.
Signature of Requestor
Date
Section 2: To be completed by the person authorizing the Department of Human Services to release their
child or dependent adult abuse information.
I understand that my signature authorizes the requester to receive information to verify whether I am named on the Child
Abuse or Dependent Adult Abuse Registry as having abused a child (Iowa Code section 235A.15) or dependent adult
(Iowa Code section 235B.6). To the best of my knowledge, the information contained in Section 1 of this form is correct.
Signature of Person Authorizing
Date
Section 3: To be completed by the Central Abuse Registry or designee.
The person whose information is being requested is listed on the Child Abuse Registry as having abused a child.
The person whose information is being requested is not listed on the Child Abuse Registry as having abused a child.
The person whose information is being requested is listed on the Dependent Adult Abuse Registry as having abused a
dependent adult.
The person whose information is being requested is not listed on the Dependent Adult Abuse Registry as having
abused a dependent adult.
This request for information is denied because the form is incomplete.
Signature of Registry Staff or Designee
Date
Comments
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Page 2
470-3301 (Rev. 2/16)
LEGAL PROVISIONS FOR HANDLING
CHILD AND DEPENDENT ADULT ABUSE INFORMATION
Redissemination of Child and Dependent Adult Abuse Information
(Iowa Code sections 235A.17 and 235B.8)
A person, agency, or other recipient of child or dependent adult abuse information shall not redisseminate
(release) this information, except that redissemination is permitted when ALL of the following conditions apply:
♦ The redissemination is for official purposes in connection with prescribed duties or, in the case of a health
practitioner, pursuant to professional responsibilities.
♦ The person to whom such information would be redisseminated would have independent access to the
same information under Iowa Code sections 235A.15 or 235B.6.
♦ A written record is made of the redissemination, including the name of the recipient and the date and
purpose of the redissemination.
♦ The written record is forwarded to the Central Abuse Registry within 30 days of the redissemination.
Criminal Penalties (Iowa Code sections 235A.21 and 235B.12)
A person is guilty of a criminal offense when the person:
♦ Willfully requests, obtains, or seeks to obtain child or dependent adult abuse information under false
pretenses, or
♦ Willfully communicates or seeks to communicate child or dependent adult abuse information to any agency
or person except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8, or
♦ Is connected with any research authorized pursuant to Iowa Code sections 235A.15 and 235B.6 and
willfully falsifies child or dependent adult abuse information or any records relating to child or dependent
adult abuse.
Upon conviction for each offense, the person is guilty of a serious misdemeanor punishable by a fine or
imprisonment.
Any person who knowingly, but without criminal purposes, communicates or seeks to communicate child or
dependent adult abuse information except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6,
and 235B.8 is guilty of a simple misdemeanor punishable, upon conviction for each offense, by a fine or
imprisonment.
Any reasonable grounds for belief that a person has violated any provision of Iowa Code Chapters 235A or
235B shall be grounds for the immediate withdrawal of any authorized access that person might otherwise
have to child or dependent adult abuse information.
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Early Childhood Education Authorization Release Child Dependent Adult Abuse Information (Indian Hills Community College)

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Completed 19 July 2020

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