Form CCL002 "Background and Registry Check S for Child Care Facilities" - Kansas

What Is Form CCL002?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL002 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL002 "Background and Registry Check S for Child Care Facilities" - Kansas

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CCL 002
Kansas Department of Health and Environment
Rev. 07/2019
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612 -1274
Child Care Program: (785) 296 -1270 Fax: (785) 559-4244
Email:
kdhe.cclr@ks.gov
Website:
www.kdheks.gov/kidsnet
BACKGROUND AND REGISTRY CHECKS FOR CHILD CARE FACILITIES
• Complete both sides of this form
• Clearly PRINT or TYPE all information
• If a person does not have a Maiden or Other name, write N/A
DIRECTIONS:
• For additional affiliates, make copies of the back page and attach all copies to this page
• INCOMPLETE FORMS WILL BE RETURNED
Program Type:
_____ Licensed Day Care Home
_____ Group Day Care Home
_____ Child Care Center
_____ Preschool
_____ Head Start Center
_____ School Age Program
_____ Drop-In Program
_____ Child Care Resource & Referral Agency
Today’s Date (MM/DD/YYYY)
Facility Name exactly AS STATED ON THE LICENSE
License #
License Expiration Date (MM/DD/YYYY)
Facility Street Address
City
Zip Code
Facility Contact Person (First and Last Name)
Facility Phone Number
Facility Email Address
The information provided on this form is to include: yourself; all individual(s) who are working or volunteering in the facility and all other individual(s) whose activities involve either
supervised or unsupervised access to children; and all individual(s) at least 10 years of age and older who are residing in the facility. DO NOT include children or youth for whom you
provide services.
This request for background and registry checks is being submitted for: (CHECK ONLY ONE OPTION BELOW)
INITIAL FACILITY APPLICATION
ADDING, UPDATING ROLE OR REMOVING PERSON(S)
RENEWAL FACILITY APPLICATION
• For a new facility, change of address, change
• For use outside of renewal time.
• Submit as part of the renewal application for the facility
• Adding new individual(s) living, working or volunteering;
of program type or change of ownership.
license.
• List ALL individuals at least 10 years of age
• List ALL individuals at least 10 years of age and older who
• Update a role change for an individual(s);
• Remove an individual(s) that are no longer living, working or
and older who are living, working or
are living, working or volunteering in the facility.
• Use form CCL 002a to update the role for EACH individual.
volunteering in the facility.
volunteering in the facility.
Please review the questions below for each individual listed on this form. If yes to any question below, please complete the information for the individual.
Name of Person
Date
Court of Action, County and State
Has been convicted of a person misdemeanor, a person felony, a sexual
offense, or a crime affecting family relationships and children?
Had a felony conviction under the uniform controlled substances act?
Has been convicted of arson?
Been adjudicated (found or determined in a court of law to be) a juvenile
offender, delinquent, or miscreant?
Has been convicted of or adjudicated of a crime that requires registration as sex
offender?
Committed physical, mental or emotional abuse or neglect or sexual abuse as
validated by DCF?
Had a child declared in a court order to be deprived or in need of care based on
allegation of physical, mental or emotional abuse or neglect or sexual abuse?
Had parental rights terminated?
Signed a diversion agreement involving child abuse or a sexual offense?
Been found to be a disabled person in need of a guardian or conservator or
both?
CCL 002
Kansas Department of Health and Environment
Rev. 07/2019
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612 -1274
Child Care Program: (785) 296 -1270 Fax: (785) 559-4244
Email:
kdhe.cclr@ks.gov
Website:
www.kdheks.gov/kidsnet
BACKGROUND AND REGISTRY CHECKS FOR CHILD CARE FACILITIES
• Complete both sides of this form
• Clearly PRINT or TYPE all information
• If a person does not have a Maiden or Other name, write N/A
DIRECTIONS:
• For additional affiliates, make copies of the back page and attach all copies to this page
• INCOMPLETE FORMS WILL BE RETURNED
Program Type:
_____ Licensed Day Care Home
_____ Group Day Care Home
_____ Child Care Center
_____ Preschool
_____ Head Start Center
_____ School Age Program
_____ Drop-In Program
_____ Child Care Resource & Referral Agency
Today’s Date (MM/DD/YYYY)
Facility Name exactly AS STATED ON THE LICENSE
License #
License Expiration Date (MM/DD/YYYY)
Facility Street Address
City
Zip Code
Facility Contact Person (First and Last Name)
Facility Phone Number
Facility Email Address
The information provided on this form is to include: yourself; all individual(s) who are working or volunteering in the facility and all other individual(s) whose activities involve either
supervised or unsupervised access to children; and all individual(s) at least 10 years of age and older who are residing in the facility. DO NOT include children or youth for whom you
provide services.
This request for background and registry checks is being submitted for: (CHECK ONLY ONE OPTION BELOW)
INITIAL FACILITY APPLICATION
ADDING, UPDATING ROLE OR REMOVING PERSON(S)
RENEWAL FACILITY APPLICATION
• For a new facility, change of address, change
• For use outside of renewal time.
• Submit as part of the renewal application for the facility
• Adding new individual(s) living, working or volunteering;
of program type or change of ownership.
license.
• List ALL individuals at least 10 years of age
• List ALL individuals at least 10 years of age and older who
• Update a role change for an individual(s);
• Remove an individual(s) that are no longer living, working or
and older who are living, working or
are living, working or volunteering in the facility.
• Use form CCL 002a to update the role for EACH individual.
volunteering in the facility.
volunteering in the facility.
Please review the questions below for each individual listed on this form. If yes to any question below, please complete the information for the individual.
Name of Person
Date
Court of Action, County and State
Has been convicted of a person misdemeanor, a person felony, a sexual
offense, or a crime affecting family relationships and children?
Had a felony conviction under the uniform controlled substances act?
Has been convicted of arson?
Been adjudicated (found or determined in a court of law to be) a juvenile
offender, delinquent, or miscreant?
Has been convicted of or adjudicated of a crime that requires registration as sex
offender?
Committed physical, mental or emotional abuse or neglect or sexual abuse as
validated by DCF?
Had a child declared in a court order to be deprived or in need of care based on
allegation of physical, mental or emotional abuse or neglect or sexual abuse?
Had parental rights terminated?
Signed a diversion agreement involving child abuse or a sexual offense?
Been found to be a disabled person in need of a guardian or conservator or
both?
Facility Name exactly AS STATED ON THE LICENSE
License #
Date
(MM/DD/YYYY)
-- ALL REQUIRED FIELDS ARE IDENTIFIED WITH AN ASTERISK (*) --
-- PLEASE PRINT CLEARLY--
-- INCOMPLETE FORMS WILL BE RETURNED --
* Role *
Suffix
* Last Name *
* First Name *
Middle Name
)
(Use only the roles listed on form CCL 002a - Affiliate Roles
(Sr., Jr., II)
ADD
* Hispanic/Latino? *
* Date of Birth *
* Gender *
Maiden/Other Name(s)
Social Security Number
)
(MM/DD/YYYY)
(Circle One)
(Circle One
UPDATE
Female or Male
Yes or No
* Race*
* Other states lived in within
* Current Address, City, State, Zip Code *
(No PO Box – only physical address accepted)
REMOVE
the last 5 years *
(Circle Only One Below)
Asian/Pacific Island
Hawaiian/Part Hawaiian
Filipino
White/Mexican/Puerto Rican/Other Caucasian
Black
Japanese
Indian (AM/CAN/AK/ALUET/ESK)
Chinese
Other Non-White
RENEWAL
Phone Number
Email
* Role *
Suffix
* Last Name *
* First Name *
Middle Name
)
(Use only the roles listed on form CCL 002a - Affiliate Roles
(Sr., Jr., II)
ADD
* Hispanic/Latino? *
* Date of Birth *
* Gender *
Maiden/Other Name(s)
Social Security Number
(MM/DD/YYYY)
(Circle One)
(Circle One
)
UPDATE
Female or Male
Yes or No
* Other states lived in within
* Current Address, City, State, Zip Code *
* Race*
REMOVE
(No PO Box – only physical address accepted)
(Circle Only One Below)
the last 5 years *
Asian/Pacific Island
Hawaiian/Part Hawaiian
Filipino
White/Mexican/Puerto Rican/Other Caucasian
Black
Japanese
Indian (AM/CAN/AK/ALUET/ESK)
Chinese
Other Non-White
RENEWAL
Phone Number
Email
* Role *
Suffix
* Last Name *
* First Name *
Middle Name
)
(Use only the roles listed on form CCL 002a - Affiliate Roles
(Sr., Jr., II)
ADD
* Hispanic/Latino? *
* Date of Birth *
* Gender *
Maiden/Other Name(s)
Social Security Number
)
(MM/DD/YYYY)
(Circle One)
(Circle One
UPDATE
Female or Male
Yes or No
* Other states lived in within
* Current Address, City, State, Zip Code *
* Race*
(No PO Box – only physical address accepted)
(Circle Only One Below)
the last 5 years *
REMOVE
Asian/Pacific Island
Hawaiian/Part Hawaiian
Filipino
White/Mexican/Puerto Rican/Other Caucasian
Black
Japanese
Indian (AM/CAN/AK/ALUET/ESK)
Chinese
Other Non-White
RENEWAL
Phone Number
Email

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