Form CCA-1229A FORFF "Provider Home Certification Request for Search of Background Checks" - Arizona

What Is Form CCA-1229A FORFF?

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

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Arizona Department of Economic Security;
  • 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 CCA-1229A FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form CCA-1229A FORFF "Provider Home Certification Request for Search of Background Checks" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1229A FORFF (6-17)
Child Care Administration
PROVIDER HOME CERTIFICATION
REQUEST FOR SEARCH OF BACKGROUND CHECKS
Reason for Request
DES District Supervisor Name
Check one:
New Applicant
Annual
New HHM/Back up
This document and any files transmitted with it are confidential and intended solely for the use of the individual
or entity to which they are addressed. If you have received this information in error, please notify the sender
and destroy the information.
The information contained in the Central Registry of Arizona Department of Child Safety (ADCS), and any attached files
shall be used as a factor to determine qualifications for individuals applying for contracts with this state, including house-
hold members of the prospective contractor, contractors, and subcontractors for positions that provide direct services to
children. The information contained in the ADCS Central Registry and any attached files are confidential and shall
not be further disseminated or shared.
Please PRINT or TYPE the information accurately and completely in all the fields below and on the subsequent pages.
PROVIDER NAME (Last, First, M.I.)
PROVIDER I.D. ASSIGNED BY DES
PHONE NUMBER (Please include area code):
EMAIL ADDRESS:
MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Name of person submitting this request (Please print):
REQUESTER’S SIGNATURE:
SUBMIT YOUR COMPLETED REQUEST TO APPROPRIATE DISTRICT SUPERVISOR.
You will receive an emailed response which contains one or more of the following results.
•Unable to process
•All Household Members cleared
•Substantiated finding (non-disqualifying)
•Substantiated finding (disqualifying) – [A list of the Disqualification Acts is attached for your information.]
•Substantiated finding (disqualifying with exception granted)
FOR INTERNAL USE ONLY
Date of search:
Number of names checked:
Checks completed by (initials):
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimina-
tion in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
Page 1 of
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1229A FORFF (6-17)
Child Care Administration
PROVIDER HOME CERTIFICATION
REQUEST FOR SEARCH OF BACKGROUND CHECKS
Reason for Request
DES District Supervisor Name
Check one:
New Applicant
Annual
New HHM/Back up
This document and any files transmitted with it are confidential and intended solely for the use of the individual
or entity to which they are addressed. If you have received this information in error, please notify the sender
and destroy the information.
The information contained in the Central Registry of Arizona Department of Child Safety (ADCS), and any attached files
shall be used as a factor to determine qualifications for individuals applying for contracts with this state, including house-
hold members of the prospective contractor, contractors, and subcontractors for positions that provide direct services to
children. The information contained in the ADCS Central Registry and any attached files are confidential and shall
not be further disseminated or shared.
Please PRINT or TYPE the information accurately and completely in all the fields below and on the subsequent pages.
PROVIDER NAME (Last, First, M.I.)
PROVIDER I.D. ASSIGNED BY DES
PHONE NUMBER (Please include area code):
EMAIL ADDRESS:
MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Name of person submitting this request (Please print):
REQUESTER’S SIGNATURE:
SUBMIT YOUR COMPLETED REQUEST TO APPROPRIATE DISTRICT SUPERVISOR.
You will receive an emailed response which contains one or more of the following results.
•Unable to process
•All Household Members cleared
•Substantiated finding (non-disqualifying)
•Substantiated finding (disqualifying) – [A list of the Disqualification Acts is attached for your information.]
•Substantiated finding (disqualifying with exception granted)
FOR INTERNAL USE ONLY
Date of search:
Number of names checked:
Checks completed by (initials):
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimina-
tion in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
Page 1 of
CCA-1229A FORFF (6-17)
Provider Name:
Provider I.D.:
Date Submitted:
INDIVIDUAL INFORMATION FOR SEARCH OF BACKGROUND CHECKS
(Please copy as many of this page as needed and number them accordingly.)
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
Page
of
CCA-1229A FORFF (6-17)
Provider Name:
Provider I.D.:
Date Submitted:
INDIVIDUAL INFORMATION FOR SEARCH OF BACKGROUND CHECKS
(Please copy as many of this page as needed and number them accordingly.)
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
Page
of
CCA-1229A FORFF (6-17)
Provider Name:
Provider I.D.:
Date Submitted:
INDIVIDUAL INFORMATION FOR SEARCH OF BACKGROUND CHECKS
(Please copy as many of this page as needed and number them accordingly.)
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
Page
of
CCA-1229A FORFF (6-17)
Provider Name:
Provider I.D.:
Date Submitted:
INDIVIDUAL INFORMATION FOR SEARCH OF BACKGROUND CHECKS
(Please copy as many of this page as needed and number them accordingly.)
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
Male
Female
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
PHYSICAL ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
Has the person lived in other state(s) in the past five (5) years?
If YES, please attach the Direct Service Position Supplement #1.
Yes
No
RELATIONSHIP
FOR INTERNAL USE ONLY
Criminal/Sex
National Crime
National Sex
DCSCR
CHILDS
Notes:
Out of State
FBI Fingerprint
Offender
Info Center
Offender
NF
NF
NF
NF
NF
NF
NF
ND
ND
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
DISQ
EXC
EXC
Page
of
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