Form DPP-157 "Background Check Request for Foster or Adoptive Applicants and Adolescent or Adult Household Members" - Kentucky

What Is Form DPP-157?

This is a legal form that was released by the Kentucky Department for Community Based Services - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Kentucky Department for Community Based Services;
  • 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 DPP-157 by clicking the link below or browse more documents and templates provided by the Kentucky Department for Community Based Services.

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Download Form DPP-157 "Background Check Request for Foster or Adoptive Applicants and Adolescent or Adult Household Members" - Kentucky

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___Adolescent Check
___Out of State Check
COMMONWEALTH OF KENTUCKY
DPP-157
___Initial w/fingerprints
CABINET FOR HEALTH AND FAMILY SERVICES
07/21
___Initial w/o/fingerprints
Department for Community Based Services
922 KAR 1:490
___Reevaluation
BACKGROUND CHECK REQUEST FOR FOSTER OR ADOPTIVE APPLICANTS
AND ADOLESCENT OR ADULT HOUSEHOLD MEMBERS
922 KAR 1:490 requires each applicant or foster or adoptive parent, and each adult household member not
enrolled in KARES, to submit to a child abuse or neglect check, criminal records check, and sex offender
registry check. 922 KAR 1:490 requires that adolescent members of households (age 12 through 17) submit
to a child abuse or neglect check. Checks shall be completed prior to initial approval and annually
thereafter. Please indicate if the check is initial or annual in the box above and check the appropriate
category below.
Adolescent Household member of DCBS Foster/Adoptive Parent or Applicant
Child placing agency – Foster/Adoptive Parent or Applicant (Not required to be enrolled in KARES)
Child placing agency – Adolescent Household Member of Foster/Adoptive Parent or Applicant
Out of State request
Out of State Request for Non-Kentucky Resident (Adam Walsh Check)
Personal information regarding the individual submitting a check.
Please list your addresses for the last five years. Use another sheet of paper, if necessary.
Name: _______________________________________________________________________________________
(first)
(middle)
(maiden/nickname)
(last)
Sex: _____ Race: _____ Date of Birth: __________________ Social Security Number: ______________________
Present Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Use another sheet of paper, if necessary.
Kentucky.gov
An Equal Opportunity Employer M/F/D
Page 1 of 3
___Adolescent Check
___Out of State Check
COMMONWEALTH OF KENTUCKY
DPP-157
___Initial w/fingerprints
CABINET FOR HEALTH AND FAMILY SERVICES
07/21
___Initial w/o/fingerprints
Department for Community Based Services
922 KAR 1:490
___Reevaluation
BACKGROUND CHECK REQUEST FOR FOSTER OR ADOPTIVE APPLICANTS
AND ADOLESCENT OR ADULT HOUSEHOLD MEMBERS
922 KAR 1:490 requires each applicant or foster or adoptive parent, and each adult household member not
enrolled in KARES, to submit to a child abuse or neglect check, criminal records check, and sex offender
registry check. 922 KAR 1:490 requires that adolescent members of households (age 12 through 17) submit
to a child abuse or neglect check. Checks shall be completed prior to initial approval and annually
thereafter. Please indicate if the check is initial or annual in the box above and check the appropriate
category below.
Adolescent Household member of DCBS Foster/Adoptive Parent or Applicant
Child placing agency – Foster/Adoptive Parent or Applicant (Not required to be enrolled in KARES)
Child placing agency – Adolescent Household Member of Foster/Adoptive Parent or Applicant
Out of State request
Out of State Request for Non-Kentucky Resident (Adam Walsh Check)
Personal information regarding the individual submitting a check.
Please list your addresses for the last five years. Use another sheet of paper, if necessary.
Name: _______________________________________________________________________________________
(first)
(middle)
(maiden/nickname)
(last)
Sex: _____ Race: _____ Date of Birth: __________________ Social Security Number: ______________________
Present Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Previous Address: ______________________________________________________________________________
(street address)
(city)
(state)
(zip code)
Use another sheet of paper, if necessary.
Kentucky.gov
An Equal Opportunity Employer M/F/D
Page 1 of 3
BACKGROUND CHECK FOR FOSTER OR ADOPTIVE APPLICANTS AND HOUSEHOLD
MEMBERS
Initial application requirements:
I hereby authorize the Cabinet for Health and Family Services to complete a check of the Kentucky Central Registry
(child abuse or neglect), Criminal Records Check, and an address check of the Sexual Offender Registry and
provide the results to the agency listed below. I further authorize the Cabinet for Health and Family Services to
complete a fingerprint Criminal Records Check (adults only). Fingerprints submitted will be used to check the
criminal history records of the Federal Bureau of Investigation (FBI). I understand I have the right to inspect my
criminal history record and to request correction of any inaccurate information. If I do not exercise that right, I
agree to hold harmless the Kentucky State Police and its employees from any claim for damages arising from the
dissemination of inaccurate information. I also release the Cabinet for Health and Family Services, its officers,
agents, and employees, from any liability or damages resulting from the release of this information.
Procedures for obtaining a copy of an FBI criminal history record are set forth at 28 C.F.R. 16.30-16.33 or go to the
FBI website at http://www.fbi.gov/about-us/cjis/background-checks. Procedures for obtaining a change, correction,
or updating of FBI criminal history records are set forth at 28 C.F.R. 16.34.
Annual application requirements:
I hereby authorize the Cabinet for Health and Family Services to complete a check of the Kentucky Central Registry
(child abuse or neglect), Criminal Records Check, and an address check of the Sexual Offender Registry and
provide the results to the agency listed below. I understand I have the right to inspect my record and to request
correction of any inaccurate information. I also release the Cabinet for Health and Family Services, its officers,
agents, and employees, from any liability or damages resulting from the release of this information.
The information provided is complete and true to the best of my knowledge. I understand if I give false information
or do not report all of the information needed, I may be subject to prosecution for fraud.
_____________________________________________________________________________________________
Signature of the individual (or parent/guardian of household member age 12-17) requesting the check
(date)*
_____________________________________________________________________________________________
Signature of witness
(date)
FOR COMPLETION BY THE CHILD PLACING AGENCY or CABINET STAFF
Name of child placing agency or DCBS office: _______________________________________________________
Name and title of representative: __________________________________________________________________
Address: _____________________________________________________________________________________
City: ________________________________________ State: _____________Zip Code: _____________________
Phone: ______________________________________ Fax:____________________________________________
Email Address to Receive Encrypted Results: ________________________________________________________
Signature: ____________________________________________________________________________________
(representative requesting information)
(date)
Send the completed form to: Email:
CHFSDCBS.RMS@ky.gov
Cabinet for Health and Family Services
Department for Community Based Services
Records Management Section
275 E. Main St., 3E-G
Frankfort, KY 40621
* Authorization provided by applicant signature expires in 60 days
Page 2 of 3
DPP-157
07/21
922 KAR 1:490
BACKGROUND CHECK FOR FOSTER OR ADOPTIVE APPLICANTS AND HOUSEHOLD
MEMBERS
Results of Child Abuse or Neglect Check
(Required of applicant and all household members age 12 and over, at initial and annual application or out-of-state
requests)
No reportable incident found in accordance with 922 KAR 1:490
Substantiated child abuse found
Date of finding:__________________________
Substantiated child neglect found
Date of finding:__________________________
The substantiated abuse or neglect finding relates to sexual abuse, sexual exploitation, a child fatality, near
fatality, or involuntary termination of parental rights:
Yes
No
A matter subject to administrative review found in accordance with 922 KAR 1:470
Results of Kentucky Criminal Records Check
(Required of applicant and all adult household members at initial and annual application)
No reportable incident was found in accordance with 922 KAR 1:490.
A reportable incident was found in accordance with 922 KAR 1:490.
Results of the address check of the Sexual Offender Registry
(Required of applicant and all adult household members at initial and annual application)
Address was not matched to an address on the sex offender registry.
Address was matched with an address associated with a registered sex offender.
Results of the Check of the Criminal History Records of FBI
(Required of applicant and all adult household members at application only)
No reportable incident found in accordance with 922 KAR 1:490.
A reportable incident was found, and in accordance with 922 KAR 1:490, Section 3(4), the applicant shall not
be approved.
A reportable incident was found, and in accordance with 922 KAR 1:490, Section 7(2), approval shall be
handled on a case-by-case basis with consideration given to the nature of the offense, length of time that has
elapsed since the event, and the applicant’s life experiences during the ensuing period of time. A criminal
records check revealed that the applicant or adult member of the applicant’s household has been convicted of a
nonviolent felony or misdemeanor (alcohol/drug or other) in the state of ______________.
Reviewed by: ____________________________________________
____________________
Records Management Staff Personnel
Date of Check
Page 3 of 3
DPP-157
07/21
922 KAR 1:490
Page of 3