Fillable Missouri Department of Health - Worker Registration Form 580-2421

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Missouri Department of Health - Worker Registration Form 580-2421

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
FAMILY CARE SAFETY REGISTRY
WORKER REGISTRATION
FCSR USE ONLY
Register online at www.health.mo.gov/safety/fcsr OR mail this form,
copy of Social Security card, and payment to Missouri Dept. of
Health and Senior Services, Fee Receipts, PO Box 570, Jefferson
City, MO 65102.
REGISTRATION TYPE (Check all that apply. Complete column on right only if Long Term Care/Personal Care selected from left.)
PERSONAL INFORMATION (Provide all names you have used, starting with most recent. Include legal names and nicknames.)
LAST NAME FIRST NAME MIDDLE NAME SUFFIX (JR., SR., II, III)
MAIDEN NAME (IF APPLICABLE) PRIOR NAMES USED (IF APPLICABLE, LIST FIRST AND LAST NAMES.) DATE OF BIRTH (MM-DD-YYYY) GENDER
M F
CONTACT INFORMATION
MAILING ADDRESS (ENTER YOUR STREET ADDRESS OR POST OFFICE BOX. THIS ADDRESS MUST BE DIFFERENT FROM EMPLOYER ADDRESS.)
CITY STATE ZIP CODE COUNTY
TELEPHONE EMAIL ADDRESS (REQUIRED) COUNTRY (COMPLETE ONLY IF OUTSIDE U.S.)
EMPLOYER ASSOCIATED WITH THIS REGISTRATION (Complete either left or right column, not both.)
REGISTRATION AGREEMENT
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information required on this
form. I grant my permission for the Missouri Department of Health and Senior Services (DHSS) to obtain any and all background information authorized by
law to process this request. Furthermore, I authorize the DHSS to release the fact that I am a registrant in the Family Care Safety Registry (FCSR) and any
related background information to the requester of the FCSR for employment purposes only, as provided in §210.921, subsection 1, subdivisions (1) and (2),
RSMo. For purposes of the FCSR, “employment purposes” includes direct employer/employee relationships, prospective employer/employee relationships,
and screening and interviewing of persons or facilities by those persons contemplating the placement of an individual in a child care, elder care or personal
care setting. I understand that if I dispute the information contained in the FCSR I have the right to appeal the accuracy of the transfer of information to the
FCSR within thirty (30) days of receiving the results of the background screening.
NOTICE: The FCSR may choose to deposit the check enclosed electronically as an ACH debit entry to my designated bank account. I understand that my
signaturebelowauthorizesmynancialinstitutiontodeductthispaymentfrommyaccount.IntheeventthatDHSSoritssubcontractorisunabletosecure
fundsfrommyaccountorIprovideinsufcientorinaccurateinformationregardingmyaccount,myobligationtotheDHSSwillremainunpaidandfurther
collection action may be taken by the DHSS or its subcontractor, including, but not limited to, returned check fees.
SIGNATURE OF APPLICANT DATE OF SIGNATURE (MUST BE WITHIN SIX MONTHS OF SUBMISSION.)
MO 580-2421 (12-18) REV. 12/18
, because I am a(n):
EMPLOYER NAME
Adoptive Parent
EMPLOYER ADDRESS
Foster Parent/Family Member
My current/potential child care, long term care or mental health care employer is: No Employer
Home Child Care Provider
EMPLOYER CITY STATE ZIP
Private Pay/Private Duty
Student
EMPLOYER TELEPHONE EMPLOYER CONTACT NAME EMPLOYER CONTACT TITLE
Volunteer
Adoptive Parent
Long Term Care / Personal Care Subcategories
(Complete if LTC/PC selected at left.)
Hospital LTAC/Swing Bed
Agency Name: __________________________________________________
Adult Day Care
Assisted Living Facility
Hospice
Mental Health – Residential Facility/ICF
Nursing Facility/Skilled Nursing
Personal Care – Home Health
Personal Care – In-Home Services
Personal Care – Consumer Directed
Services/Center for Independent Living
Personal Care – HCY/PDW/DDD/Other
Child Care
Foster Parent/Family Member of Foster Parent
CountyOfce: __________________________________________________
Hospital
Long Term Care/Personal Care (Please choose subcategory at right 4.)
Mental Health/Psychiatric Hospital
Voluntary (Select voluntary if no other registration type applies.)
A one-time registration fee of $14.00 applies to all categories except Foster Parents.
FosterParentsmustlisttheChildren’sDivisioncountyofce.
Register only once. If you believe you have already registered, check our website at
www.health.mo.gov/safety/fcsr or call, toll free, 866-422-6872.
SOCIAL SECURITY NUMBER (Mail copy of card with form.)
– –
Other (Explain: )
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WHAT IS THE FAMILY CARE SAFETY REGISTRY?
The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provides families and
employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen
child care, long term care and mental health workers:
• State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol
• Child abuse/neglect records maintained by the Missouri Department of Social Services
• TheEmployeeDisqualicationListmaintainedbytheMissouriDepartmentofHealthandSeniorServices
• TheEmployeeDisqualicationRegistrymaintainedbytheMissouriDepartmentofMentalHealth
• Child care facility licensing records maintained by the Missouri Department of Health and Senior Services
• Foster parent records maintained by the Missouri Department of Social Services
WHO HAS TO REGISTER?
Any person hired on or after January 1, 2001, as a child care worker or elder care worker, hired on or after January 1, 2002, as a personal care worker,
or hired on or after January 1, 2009, as a mental health worker, as provided in §210.906, RSMo, is required to make application for registration in the
FamilyCareSafetyRegistrywithinfteen(15)daysofthebeginningofemployment.Suchpersonwhofailstosubmitacompletedregistrationformto
the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and volunteers from non-state and/or
federally regulated entities are NOT REQUIRED to register with the FCSR.
HOW DO I COMPLETE THE REGISTRATION FORM?
Registration Type – Check at least one box from the left column for type of registration that best describes your worker category. If no other type applies,
select “Voluntary.” (A “voluntary registrant” is a person who is not mandated to register with the Family Care Safety Registry pursuant to §210.900 et
seq., RSMo.) If you checked Long Term Care / Personal Care, please also make one or more selections from the column on the right for subcategory.
Social Security Number – You must provide your Social Security number pursuant to 19CSR 30-80.030(1). This identifying information, including Social
Securitynumber,willbeusedforinternalidenticationpurposesandtoconductbackgroundscreeningsfortheresourceinformationlistedinparagraph
one above.
Personal Information–ListyourcurrentLastName,FirstName,MiddleName,andanysufxassociatedwithyourlastname.Listanyothernamesby
whichyoumayhavebeenknown,includingmaidennames,pastmarriednames,andnicknames(attachadditionalsheetsifneeded).Foridentication
purposes, list your gender and date of birth.
Contact Information – List your address, city, state, ZIP code, and county. Include your telephone number and email address. We will use this information
tonotifyyouofregistrationresultsandanybackgroundscreeningsconducted.Emailnoticationswillbeencryptedforimprovedsecurity.Toreduce
postage costs, the Registry may contact you to request a personal email address if one is not provided.
Employer Associated with this Registration - If you are currently employed by or are seeking employment with a child care or long term care provider,
please list the facility name, address, telephone number, and contact person. If registration is not for employment purposes, make a selection from
columnonright.Theemployerenteredinthissectionwillnotreceiveacopyoftheregistrationnotication.Employers eligible to use the Registry for
caregiver screenings must make a separate request for your background information.
Registration Agreement – Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background
screening outlined in §210.903.2, RSMo and to provide the information to requesters for employment purposes, as provided in §210.921.1, RSMo.
WHERE DO I SEND MY REGISTRATION FORM?
Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior
Services, ATTN: Fee Receipts, P.O. Box 570, Jefferson City, MO 65102. If you have questions, please call the Registry using the toll-free telephone
number, 866-422-6872.
WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND SCREENING?
Afterthebackgroundscreeninghasbeencompleted,youwillbenotiedinwritingoftheresultsthatwillberecordedintheFamilyCareSafetyRegistry.
Youwillalsobenotiedinwritingeachtimebackgroundscreeninginformationisprovided.Thenoticationwillcontainthenameandaddressofthe
person who made the request and the background information disclosed. The person making the request will be informed that information will be
released for employment purposes only, pursuant to §210.921.1, RSMo. Any person using Registry information for any other purpose is guilty of a class
B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry
obtains the name and address of the requester, and determines that the request is for employment or regulatory purposes. To ensure you receive these
notications,itwillbeimportantforyoutonotifytheFamilyCareSafetyRegistrywhenyouhaveachangeinyourcontactinformation.NotifytheFamily
Care Safety Registry of changes in personal or contact information using the toll-free telephone number, 866-422-6872, by email to fcsr@health.mo.gov,
or by mail to FCSR, PO Box 570, Jefferson City, MO 65102.
WHAT IF I DON’T AGREE WITH THE RESULTS OF MY BACKGROUND SCREENING?
As provided in §210.912, RSMo, you have the right to appeal the information transferred to the Family Care Safety Registry. Your right to appeal is limited
to the accuracy of the transfer of information from the state agency that maintains the background information and does not include a right to appeal the
accuracyofthesubstanceoftheinformationtransferred.AnappealmustbeledinwritingtotheOfceoftheDirector,MissouriDepartmentofHealth
and Senior Services, P.O. Box 570, Jefferson City, MO, 65102, within 30 days of receiving the results of the background screening determination. An
administrativeappealshallbesetwithin30daysofthelingoftheappealandadecisionshallbemadewithin60days.Thisrighttoappealisinaddition
to any other appeal rights granted by state law.
WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY?
Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. If the person is registered, the Registry
workerwilldisclosewhethertheperson’snameislistedinanyofthebackgroundcheckspursuantto§210.903,subsection2,RSMo,andifso,which
one(s).SpecicinformationwillbedisclosedbytheRegistrypursuantto§210.921,subsection1,subdivision(2).
MO 580-2421 (FP) REV. 12/18
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Missouri Department of Health - Worker Registration Form 580-2421

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Completed 26 May 2020

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