Form LIC198B "Out-Of-State Child Abuse/Neglect Report Request" - California

What Is Form LIC198B?

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

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the California Department of Social 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 fillable version of Form LIC198B by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC198B "Out-Of-State Child Abuse/Neglect Report Request" - California

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State of California – Health and Human Services Agency
California Department of Social Services
OUT-OF-STATE CHILD ABUSE/NEGLECT REPORT REQUEST
ADAM WALSH CHILD PROTECTION AND SAFETY ACT OF 2006
Additional child abuse/neglect check for persons who have lived out-of-state in the last five years.
In addition to the California criminal background and child abuse central index checks, an applicant
for TrustLine Registry, Transitional Housing Placement Provider, Children Crisis Residential
Program, Group Home, Short-Term Residential Therapeutic Program, Community Treatment Facility,
Small Family Home, resource family approval and any person over the age of 18 working in any
aforementioned children’s residential facility or residing in the home of an applicant, resource family,
licensed foster family home, certified family home, or small family home is subject to an out-of-state
child abuse/neglect check if they have lived out-of-state within the last five years. If you have lived
out-of-state in the last five (5) years you must complete this form and sign below to authorize
a check of the child abuse/neglect registry in that state in order to be licensed, approved or
cleared to work or reside in the home.
IDENTIFYING DATA (Please type or print information legibly in ink.)
INDIVIDUAL’S NAME (Last, First, MI, Jr., Sr., III)
TELEPHONE NUMBER EMAIL ADDRESS
MAIDEN NAME
DATE OF BIRTH
STATE OF BIRTH SEX
RACE
(MM/DD/YY)
ALIAS NAME(S)
SOCIAL SECURITY NUMBER -
DRIVER’S LICENSE
See Privacy Statement On Page 3
NUMBER/STATE
ADDRESSES FOR PAST 5 YEARS
STREET
CITY
STATE
STREET
CITY
STATE
Has an allegation of child abuse or neglect ever been substantiated against you in this state
or any state?
YES (Complete below)
NO, an allegation of child abuse or neglect has never been substantiated against me.
CIRCUMSTANCES
DATE
CITY
STATE
COUNTY
(Attach separate page, if necessary.)
LIC 198B (3/20)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
OUT-OF-STATE CHILD ABUSE/NEGLECT REPORT REQUEST
ADAM WALSH CHILD PROTECTION AND SAFETY ACT OF 2006
Additional child abuse/neglect check for persons who have lived out-of-state in the last five years.
In addition to the California criminal background and child abuse central index checks, an applicant
for TrustLine Registry, Transitional Housing Placement Provider, Children Crisis Residential
Program, Group Home, Short-Term Residential Therapeutic Program, Community Treatment Facility,
Small Family Home, resource family approval and any person over the age of 18 working in any
aforementioned children’s residential facility or residing in the home of an applicant, resource family,
licensed foster family home, certified family home, or small family home is subject to an out-of-state
child abuse/neglect check if they have lived out-of-state within the last five years. If you have lived
out-of-state in the last five (5) years you must complete this form and sign below to authorize
a check of the child abuse/neglect registry in that state in order to be licensed, approved or
cleared to work or reside in the home.
IDENTIFYING DATA (Please type or print information legibly in ink.)
INDIVIDUAL’S NAME (Last, First, MI, Jr., Sr., III)
TELEPHONE NUMBER EMAIL ADDRESS
MAIDEN NAME
DATE OF BIRTH
STATE OF BIRTH SEX
RACE
(MM/DD/YY)
ALIAS NAME(S)
SOCIAL SECURITY NUMBER -
DRIVER’S LICENSE
See Privacy Statement On Page 3
NUMBER/STATE
ADDRESSES FOR PAST 5 YEARS
STREET
CITY
STATE
STREET
CITY
STATE
Has an allegation of child abuse or neglect ever been substantiated against you in this state
or any state?
YES (Complete below)
NO, an allegation of child abuse or neglect has never been substantiated against me.
CIRCUMSTANCES
DATE
CITY
STATE
COUNTY
(Attach separate page, if necessary.)
LIC 198B (3/20)
Page 1 of 3
State of California – Health and Human Services Agency
California Department of Social Services
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
permission to the California Department of Social Services to check with state(s) and/or
counties listed above to obtain any and all information needed to process my request and to
use the information as permitted by law.
SIGNATURE OF INDIVIDUAL (Required In Ink)
DATE
SIGNATURE OF WITNESS (Required In Ink)
DATE
REQUESTOR INFORMATION:
DEPARTMENT OF SOCIAL SERVICES
FOR CBCB STAFF ONLY
COMMUNITY CARE LICENSING
NAME OF REQUESTOR
CAREGIVER BACKGROUND CHECK BUREAU
744 P STREET, MS T9-15-62
SACRAMENTO, CA 95814
FAX
TELEPHONE NUMBER
EMAIL ADDRESS
RESPONDING STATE:
(PLEASE RETURN BY FAX, MAIL OR EMAIL TO THE REQUESTOR LISTED ABOVE.)
The result of a name search in the State Child Abuse/Neglect Registry is as follows:
The subject of the attached report MAY be the same as the subject of your inquiry.
REPORT DATE
REPORT NO.
LOCAL CONTACT
PHONE NUMBER/FAX
No record on the above listed person.
Too many possible matches to identify. See attached listing.
CONTACT NAME
AGENCY
TELEPHONE NUMBER
EMAIL
LIC 198B (3/20)
Page 2 of 3
State of California – Health and Human Services Agency
California Department of Social Services
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil
Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on
this form. The California Department of Justice uses a person’s SSN as an identifying number. The
requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and
the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires
that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09,
1569.17, 1596.871, and 1796.19). The Department will create a file concerning your criminal
background check that will contain certain documents, including information that you provide.
You have the right to access certain records containing your personal information maintained by
the Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the
Department may have to provide copies of some of the records in the file to members of the public
who ask for them, including newspaper and television reporters.
NOTE: IMPORTANT INFORMATION
With the exception of Foster Family Homes, Certified Family Homes, Small Family Childcare
Homes, and Resource Family Approval Homes, the Department is required to tell people who ask,
including the press, if someone in a licensed facility/organization has a criminal record exemption.
The Department must also tell people who ask, the name of a licensed facility/organization that has
a licensee, employee, resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
LIC 198B (3/20)
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