Form OCC1260 "Release of Information - Child Care" - Maryland

What Is Form OCC1260?

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

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Maryland State Department of Education;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OCC1260 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form OCC1260 "Release of Information - Child Care" - Maryland

Download PDF

Fill PDF online

Rate (4.5 / 5) 72 votes
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
RELEASE OF INFORMATION – Child Care
Child Care regulations require signed and notarized permission to examine records of child and adult abuse and neglect for information about
the applicant/operator (if the applicant/operator is an individual) or family child care provider/co-provider; each child care center employee or
staff member; each adult, 18 years old or older, living on the premises of the child care facility or applicant; each family child care substitute
and additional adult; each trustee, manager, and board member, who may have frequent contact with children in care, if the applicant/operator
is a corporation, agency, association, or other organizational entity; and any other individual identified by the Office.
Facility Name and address: ___________________________________________________________________________________________
(Name of Family Child Care Provider or Facility)
STATEMENT OF PERMISSION
I hereby authorize the Local Department of Social Services (DSS) to release to the Office of Child Care (OCC) any files or records of
child and adult abuse or neglect in order to help OCC evaluate my suitability for employment in or by a child care center, or determine
whether to approve the issuance or maintenance of an initial or continuing license, letter of compliance or registration for the above named
facility.
Furthermore, I understand that the information obtained by OCC from the State or Local Department of Social Services may provide
grounds for OCC to prohibit or require termination of my employment at the child care center, or deny, suspend, or revoke the license, letter
of compliance, registration or application of the Child Care Center, Family Child Care Provider or Applicant/Operator named above.
_________________________________________________________________________ |________________________________
Print Name
First
Middle
Maiden
Last
Other Names Used
__________________________________________________________________________________________________________
Address:
Street
City
State
Zip Code
________________________ ____________________
____________
____________________________________________
Telephone Number
Social Security Number
Date of Birth
Email Address
Prior Addresses (List all within the last 5 years outside of Maryland. Use additional pages as needed)
_________________________________________________________________________________________________________
Street Address
City, State, Zip Code
Dates of Residence
__________________________________________________________________________________________________________
Street Address
City, State, Zip Code
Dates of Residence
Male
Female
Primary Language Spoken: __________________
Position____________________________________
Employee, Resident, Substitute, Volunteer, etc.
Race (check all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific
Islander
White
Other (specify): ____________________
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
If I am not the Applicant/Operator or Provider, I authorize OCC to release this information to an authorized representative of the Child
Care Center, or to the Family Child Care Provider or the Applicant/Operator.
_________________________________________________
Signature
Date
_________________________________________________
Notary Signature
My commission Expires: __________
Page 1 of 2
(for OCC use only)
Background Clearance Findings
Person Conducting Search _________________________Date: __________________
1. T
he individual whose name is being searched is NOT identified in the Central Confidential Database for abuse or neglect.
2. Based on the information provided by the Local Department of Social Services, we have determined that the individual is listed in the Central
Confidential Database as being
Indicated or
Unsubstantiated for
abuse or
neglect in reference to an investigation conducted in ___________.
3
. 181 and/or summary was received from Local Department of Social Services on_____________________________.
4. The above named individual
is or
is not cleared for involvement in the Child Care Facility with the following restrictions: __________________.
_________________________________________________________
Regional Manager/Designee Signature
Date
OCC 1260 – Revised 6/18 – All previous editions are obsolete
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
RELEASE OF INFORMATION – Child Care
Child Care regulations require signed and notarized permission to examine records of child and adult abuse and neglect for information about
the applicant/operator (if the applicant/operator is an individual) or family child care provider/co-provider; each child care center employee or
staff member; each adult, 18 years old or older, living on the premises of the child care facility or applicant; each family child care substitute
and additional adult; each trustee, manager, and board member, who may have frequent contact with children in care, if the applicant/operator
is a corporation, agency, association, or other organizational entity; and any other individual identified by the Office.
Facility Name and address: ___________________________________________________________________________________________
(Name of Family Child Care Provider or Facility)
STATEMENT OF PERMISSION
I hereby authorize the Local Department of Social Services (DSS) to release to the Office of Child Care (OCC) any files or records of
child and adult abuse or neglect in order to help OCC evaluate my suitability for employment in or by a child care center, or determine
whether to approve the issuance or maintenance of an initial or continuing license, letter of compliance or registration for the above named
facility.
Furthermore, I understand that the information obtained by OCC from the State or Local Department of Social Services may provide
grounds for OCC to prohibit or require termination of my employment at the child care center, or deny, suspend, or revoke the license, letter
of compliance, registration or application of the Child Care Center, Family Child Care Provider or Applicant/Operator named above.
_________________________________________________________________________ |________________________________
Print Name
First
Middle
Maiden
Last
Other Names Used
__________________________________________________________________________________________________________
Address:
Street
City
State
Zip Code
________________________ ____________________
____________
____________________________________________
Telephone Number
Social Security Number
Date of Birth
Email Address
Prior Addresses (List all within the last 5 years outside of Maryland. Use additional pages as needed)
_________________________________________________________________________________________________________
Street Address
City, State, Zip Code
Dates of Residence
__________________________________________________________________________________________________________
Street Address
City, State, Zip Code
Dates of Residence
Male
Female
Primary Language Spoken: __________________
Position____________________________________
Employee, Resident, Substitute, Volunteer, etc.
Race (check all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific
Islander
White
Other (specify): ____________________
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
If I am not the Applicant/Operator or Provider, I authorize OCC to release this information to an authorized representative of the Child
Care Center, or to the Family Child Care Provider or the Applicant/Operator.
_________________________________________________
Signature
Date
_________________________________________________
Notary Signature
My commission Expires: __________
Page 1 of 2
(for OCC use only)
Background Clearance Findings
Person Conducting Search _________________________Date: __________________
1. T
he individual whose name is being searched is NOT identified in the Central Confidential Database for abuse or neglect.
2. Based on the information provided by the Local Department of Social Services, we have determined that the individual is listed in the Central
Confidential Database as being
Indicated or
Unsubstantiated for
abuse or
neglect in reference to an investigation conducted in ___________.
3
. 181 and/or summary was received from Local Department of Social Services on_____________________________.
4. The above named individual
is or
is not cleared for involvement in the Child Care Facility with the following restrictions: __________________.
_________________________________________________________
Regional Manager/Designee Signature
Date
OCC 1260 – Revised 6/18 – All previous editions are obsolete
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
RELEASE OF INFORMATION – Child Care
Name:
To ensure that the information obtained is for the correct individual, please provide additional family history information requested below.
Full names and birth dates of your child(ren) including, if any, whether living with you or not: NOTE: If none, check this box
Child’s First Name
Middle Name
Last Name
Date of Birth
Page 2 of 2
OCC 1260 – Revised 6/18 – All previous editions are obsolete
Page of 2