Get IA DHS 470-2310 2011

Iowa Department of Human Services Record Check Evaluation Date To HEALTH CARE FACILITIES AND HCB WAIVER PROGRAMS Complete Part A. I can work in an HCB waiver program. 470-2310 Rev. 6/11 Copy 1 DHS Service Area or Central Office Copy 2 Control Page 2 D. Fill in your agency name address and hiring person in Part B. Have the person being evaluated complete Part C and Part D of the form and return it to you. Then address and mail it to Department of Human Services Central Abuse Registry PO Box 4826 Des Moines Iowa 50305 A. A background check has revealed A founded child abuse report placed on the Child Abuse Registry. Name of person being evaluated A founded dependent adult abuse report. A criminal conviction* Other specify B. Please complete Page 2 of this form to enable the Department to further assess the report and return the form to DHS or Agency Office Attention Phone Street City State C. Zip Code RESPONSE completed by person requesting evaluation I do not wish to have the report assessed further because I am withdrawing my application* I will not be involved in any of the situations listed below. I wish to have the report evaluated to determine if I can be approved as an adoptive parent. I can be licensed or registered for child day care. The family with whom I live can be a registered home or a licensed center for child day care. I can work or volunteer in a foster care facility a child care center or a public institution under DHS* I can work in a licensed health care facility. Description of the Incident completed by person requesting evaluation Describe type of crime child or dependent adult abuse or transgression in which you were involved* a* Date b. Location c* Circumstances d. Others involved including the victim e. Age of the victim Describe your efforts to change your behavior or correct the situation* Include restitution time in jail parenting classes counseling therapy or other things that you have done. You may attach supporting documents. Explain why you think your application should be approved in spite of the abuse or crime described above. If the Department has ever previously evaluated your record give the date place position sought and results. I realize that this information may be verified with local law enforcement agencies the district court or other persons having knowledge of the incident. Fill in your agency name address and hiring person in Part B. Have the person being evaluated complete Part C and Part D of the form and return it to you. Then address and mail it to Department of Human Services Central Abuse Registry PO Box 4826 Des Moines Iowa 50305 A. Then address and mail it to Department of Human Services Central Abuse Registry PO Box 4826 Des Moines Iowa 50305 A. A background check has revealed A founded child abuse report placed on the Child Abuse Registry. Name of person being evaluated A founded dependent adult abuse report. A background check has revealed A founded child abuse report placed on the Child Abuse Registry. Name of person being evaluated A founded dependent adult abuse report. A criminal conviction* Other specify B. Please complete Page 2 of this form to enable the Department to further assess the report and return the form to DHS or Agency Office Attention Phone Street City State C. .