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Missouri Credentialing Board (Missouri Credentialing Board)

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Revised 10/14 1
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
(573) 616-2303 (FAX) email: help@missouricb.com Jefferson City, MO 65101
Dear Applicant:
Following is the Child Abuse/Neglect Statement that must be filled out and returned with your
application for a MCB credential.
Additional items that should be included with this form are:
1) A copy of the incident report from the Division of Family Services. To obtain a copy,
call DFS at 573-751-2330.
2) If you were put under any type of court supervision due to the incident, provide
verification that you are completely off of any court supervision.
All materials submitted to the MCB will be considered during your application review. The Board
reserves the right to deny an application based on past history of child abuse/neglect cases.
However, the Board also recognizes that people and circumstances do change. Consequently, a past
child abuse/neglect case does not mean that an application will not be approved. The authority to
make this decision rests solely with the Board.
If you have any questions, please feel free to contact the MCB Board office at 573-616-2300.
Sincerely,
Stacey Langendoerfer
Director
Revised 10/14 2
CHILD ABUSE/NEGLECT STATEMENT
NAME: _________________________________________________________________________
Child Abuse/Neglect related incident(s) and date(s):______________________________________
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DFS action taken: _________________________________________________________________
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State where incident happened: ______________________________________________________
If incident occurred in state other than Missouri, please request a report from that state and
submit with this statement.
Are you presently under court supervision of any kind? ________
(You may not apply for a MCB credential while under court supervision)
Provide details related to the incident(s):
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Revised 10/14 3
Describe what actions you have taken since the last incident to ensure that a child abuse/neglect
incident does not happen again in the future:
________________________________________________________________________________
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Use this space to make any other comment or statement regarding any prior DFS incident(s) and
your life since:
________________________________________________________________________________
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APPLICANT’S SIGNATURE:
Your signature assures that all of the information that you provided in this form is complete and true and that you
accept the Board’s responsibility and authority to approve or not approve any application for credentialing by the
Board.
_______________________________________________________________________________
Applicant’s Signature Date
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Completed 28 August 2020

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