"Petition to Remove Neglect Finding From the Employment Clearance (Cna) Registry" - Arkansas

Petition to Remove Neglect Finding From the Employment Clearance (Cna) Registry is a legal document that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas.

Form Details:

  • Released on September 1, 2007;
  • The latest edition currently provided by the Arkansas Department of Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download "Petition to Remove Neglect Finding From the Employment Clearance (Cna) Registry" - Arkansas

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Division of Provider Services
and Quality Assurance
Office of Long Term Care
http://humanservices.arkansas.gov/dms/Pages/oltcHome.aspx
PO Box 8059, Slot S405, Little Rock, AR 72203-8059
501-320-6500
Petition to Remove Neglect Finding from the
Employment Clearance (CNA) Registry Instructions
The following information is provided to guide you through the application process to Petition
this Office for removal of a substantiated “neglect” finding on the Long Term Care Facility
Employment Clearance (CNA) Registry.
Failure to provide complete information or required documents may result in delay of processing
or closure of your petition application.
1. Submit a letter requesting the removal of the neglect finding. This letter must contain the
following information:
Full name and current mailing address
Day-time phone number
Social Security Number
Date of birth
2. Written statements of at least two personal character references.
3. Letter(s) of reference from any employment within the previous year from the date of the
petition request. This letter must include a statement attesting to the petition applicant’s
work performance in relation to the lack of any incidents involving abusive or negligent
behavior.
4. Submit signed and notarized forms (enclosed) authorizing release of information from the
Child Maltreatment Central Registry and the Adult Maltreatment Central Registry. Include
$10 payment for Child Maltreatment Central Registry.
5. A current criminal record report from the Arkansas State Police (form enclosed). If you
currently or within the previous 12 months have lived in another state, a criminal record
report must be provided from that state. Criminal record check reports must be an original
document and copies will not be accepted.
You are responsible for paying all fees related to obtaining criminal record check reports. The
Arkansas State Police criminal record check results will be sent directly from the Arkansas
State Police to the Office of Long Term Care. Please note all references must be hand written
and signed with a contact number.
Submit all documents (except the criminal record check form and payment) to the following
address:
Office of Long Term Care
Nursing Assistant Training Program
Mail Slot S-405
P.O. Box 8059
Little Rock, AR 72203-8059
humanservices.arkansas.gov
Protecting the vulnerable, fostering independence and promoting better health
Division of Provider Services
and Quality Assurance
Office of Long Term Care
http://humanservices.arkansas.gov/dms/Pages/oltcHome.aspx
PO Box 8059, Slot S405, Little Rock, AR 72203-8059
501-320-6500
Petition to Remove Neglect Finding from the
Employment Clearance (CNA) Registry Instructions
The following information is provided to guide you through the application process to Petition
this Office for removal of a substantiated “neglect” finding on the Long Term Care Facility
Employment Clearance (CNA) Registry.
Failure to provide complete information or required documents may result in delay of processing
or closure of your petition application.
1. Submit a letter requesting the removal of the neglect finding. This letter must contain the
following information:
Full name and current mailing address
Day-time phone number
Social Security Number
Date of birth
2. Written statements of at least two personal character references.
3. Letter(s) of reference from any employment within the previous year from the date of the
petition request. This letter must include a statement attesting to the petition applicant’s
work performance in relation to the lack of any incidents involving abusive or negligent
behavior.
4. Submit signed and notarized forms (enclosed) authorizing release of information from the
Child Maltreatment Central Registry and the Adult Maltreatment Central Registry. Include
$10 payment for Child Maltreatment Central Registry.
5. A current criminal record report from the Arkansas State Police (form enclosed). If you
currently or within the previous 12 months have lived in another state, a criminal record
report must be provided from that state. Criminal record check reports must be an original
document and copies will not be accepted.
You are responsible for paying all fees related to obtaining criminal record check reports. The
Arkansas State Police criminal record check results will be sent directly from the Arkansas
State Police to the Office of Long Term Care. Please note all references must be hand written
and signed with a contact number.
Submit all documents (except the criminal record check form and payment) to the following
address:
Office of Long Term Care
Nursing Assistant Training Program
Mail Slot S-405
P.O. Box 8059
Little Rock, AR 72203-8059
humanservices.arkansas.gov
Protecting the vulnerable, fostering independence and promoting better health
ARKANSAS DEPARTMENT OF HUMAN SERVICES
REQUEST FOR ADULT MALTREATMENT REGISTRY INFORMATION
Print all information in ink.
Name
Date of Birth
Maiden Name and/or Any Names Formerly Used
Social Security Number
Email Address
Current Address (Street, City, State, Zip)
List all previous addresses for the past five years. (Attach additional pages, if needed.)
Dates (From/To)
I authorize Department of Human Services/Adult Protective Services to release information from the Adult
Maltreatment Central Registry in accordance with Ark. Code Ann. § 12-12-1717 to the following:
Agency Name/Contact Person
Agency type:
Nurse Aide Registry
Volunteer (no charge)
Non-Profit (no charge)
Division of Provider Services and Quality Assurance
State Agency (no charge)
All Others ($10.00 Fee)
Mailing Address (Street or PO Box, City, State, Zip)
PO Box 8059 Slot S405
Little Rock AR 72203
I further certify that the information provided on this form is true and correct.
Signature________________________________________________ Date ______________________
Notarization Required
COUNTY OF ___________________
STATE OF ARKANSAS
Acknowledged before me this ________ day of __________________, 20_____.
___________________________________
_____________________
[SEAL]
Notary Public
My Commission Expires
For APS use only:
The above named applicant was _____ / was not _____ listed in the Adult Maltreatment Central Registry.
Verified by: ________
MAIL THE COMPLETED FORM TO:
Adult Maltreatment Central Registry - Slot W240
PO Box 1437
Little Rock, AR 72203
Email:
aamr@dhs.arkansas.gov
Fax: 501-682-6393
Authorization for Release of Confidential Information
Contained Within the Arkansas Child Maltreatment Central Registry
I hereby request that the Arkansas Child Maltreatment Central Registry, PO Box 1437, Slot S 566, Little Rock, Arkansas 72203,
release any information their files may contain indicating the undersigned applicant as an offender of true report of child maltreatment.
Arkansas law now permits Central Registry to charge a fee for child maltreatment background checks, investigative files, photos,
audio and video recordings. This request will be NOT be processed if you do not return it to us with a check or money order for
$10.00 made payable to the Department of Human Services. We are unable to accept cash. If you feel that you should not have to
pay this fee, please provide us with your proof of 501C3.
Note: DHHS internal request, no fee payment required
This information should be addressed to:
Nurse Aide Registry, Office of Long Term Care, PO Box 8059, Mail Slot S-405, Little Rock, AR 72203
I understand that the name of any confidential informants, or other information which does not pertain to the applicant as alleged
perpetrator, will not be released.
Applicant’s Name (print or type)
Social Security Number
Maiden Name/Aliases
Full Name/DOB children
Race
Age/DOB
Full Name/DOB children
Present Address:
Full Name/DOB children
From
to
Past address:
Full Name/DOB children
From
to
From
to
Applicant’s Signature
From
to
County of
State of Arkansas
Acknowledges before me this
day of
200
.
My commission expires:
Notary Public
ARKANSAS STATE POLICE
ASP-122
(Rev. 09/07)
Identification Bureau
Individual Record Check Form
Procedure For Criminal History Check
1. The ASP form 122, Individual Record Check Form, must be completed in its entirety.
2. A check or money order in the amount of $25.00 made payable to the Arkansas State Police,
must be included.
3. If the request is presented in person, the person requesting must present a photo I.D. issued by
a government agency.
4. If the request is made by mail, the signature on the ASP form 122 must be notarized.
5. If the request is made by mail, a self-addressed envelope with sufficient return postage must
be included.
6. If the request is made in person at our office by a third party, such as an employment agency
or employer, the ASP form 122 must be notarized.
7. If the request is required by a particular licensing entity as mandated by state law, such as
teachers, health care or police, please contact the appropriate licensing entity to obtain the
proper forms and be advised of the correct procedure to obtain a criminal history.
Send requests to:
Arkansas State Police
Identification Bureau
#1 State Police Plaza Dr.
Little Rock, AR 72209
To contact the Identification Bureau, you may call 501-618-8500.
SEE OTHER SIDE FOR APPLICATION
ARKANSAS STATE POLICE
ASP-122
(Rev. 09/07)
Identification Bureau
Individual Record Check Form
Full Name: ________________________________________________________/__________________
First
Middle
Last Name
Maiden/Other
Date of Birth: ____________________________ State of Birth: ___________Race: ____Sex: ____
(Month/Day/Year)
Social Security #: ________________________________ Driver’s License #: __________________
State
Mailing Address: ______________________________________________________________________
Street
City
State
ZIP
Daytime Phone #: (_____)____________________________
I GIVE MY CONSENT FOR THE ARKANSAS STATE POLICE TO CONDUCT A CRIMINAL
RECORD SEARCH ON MYSELF AND RELEASE ANY RESULTS TO THE FOLLOWING
PERSON OR ENTITY:
DHS/DPSQA NURSING ASSISTANT REGISTRY
Name: ________________________________________________________________________________
(First/MI/Last Name) or Full Name of Agency
PO BOX 8059 SLOT S-405
LITTLE ROCK
AR
72203
Mailing Address: ______________________________________________________________________
Street
City
State
ZIP
Signature: ______________________________________________________ Date: _______________
(First/MI/Last Name)
(Month/Day/Year)
(NO REQUEST WILL BE PROCESSED WITHOUT A NOTARIZED SIGNATURE)
STATE OF _____________________________________
§
COUNTY OF ____________________________________
Subscribed and sworn before me, a Notary Public, in and for the county and state
aforesaid, this the ______________ day of ____________________, 20 ________________ .
_________________________________
Notary Public
82004 State Record Check
82005 State Record Check
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