Fillable Missouri Department of Health - Employer Criminal Background Check Notification Form

Fill Online, Printable, Fillable, Blank Missouri Department of Health - Employer Criminal Background Check Notification Form Form

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Missouri Department of Health - Employer Criminal Background Check Notification Form

On average this form takes 27 minutes to complete

The Missouri Department of Health - Employer Criminal Background Check Notification Form form is 1 page long and contains:

  • 0 signatures
  • 7 check-boxes
  • 104 other fields

Country of origin: US
File type: PDF

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FACILITY NAME
DVN
OWNER
CONTACT PERSON
EMAIL ADDRESS
PHONE NUMBER
MAILING ADDRESS
CITY
ZIP CODE
COUNTY
FACILITY TYPE
☐ FAMILY CHILD CARE HOME ☐ GROUP CHILD CARE HOME ☐ CHILD CARE CENTER ☐ NURSERY SCHOOL
STATUS
☐ LICENSED ☐ LICENSE EXEMPT ☐ PENDING LICENSURE
EMPLOYEE(S)/APPLICANT(S) TO BE FINGERPRINTED
LAST NAME (CURRENT/LEGAL) FIRST NAME (CURRENT/LEGAL) MI SOCIAL SECURITY NUMBER DATE OF BIRTH
HAS THIS INDIVIDUAL LIVED IN ANY OTHER STATE(S)
BESIDES MISSOURI WITHIN THE PAST 5 YEARS? (YES/NO)
IF YES, PLEASE LIST OTHER STATE(S).
DATE FINGERPRINTS WERE TAKEN
This information provided is completed and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this form. I request that a copy of the eligible or ineligible letter for the above individuals be sent
to me. I understand that prospective child care staff members shall be supervised at all times by another child care staff member who received a qualifying result on the criminal background check within the past five years.
SIGNATURE OF OWNER(S)/BOARD CHAIRPERSON/DESIGNEE (CIRCLE APPROPRIATE TITLE)
DATE
DHSS-CCR-21 (12-18) 1
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION
EMPLOYER CRIMINAL BACKGROUND CHECK NOTIFICATION
Email this form to sccrcbs@health.mo.gov
or fax to 573-526-5345.
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Missouri Department of Health - Employer Criminal Background Check Notification Form

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Completed 26 May 2020

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