INSTRUCTIONS FOR COMPLETING THE
CHILD ABUSE/NEGLECT CENTRAL REGISTRY CLEARANCE REQUEST (DHR-FCS-1598)
Purpose: This form is used to request information from the Child Abuse/Neglect (CA/N) Central Registry for employees or potential employees who will provide unsupervised care and supervision for children.
Instructions: The person/agency/organization requesting the clearance must provide an original (with original signatures) and one (1) copy of the1598 Form with all information completed. The 1598 must be signed and dated (in the appropriate locations) by the person or agency/organization requesting the clearance, the person being cleared, and a witness. Completed 1598s must be submitted within ninety (90) days of the date the form was signed by the person to be cleared.
Employees or potential employees of child placing agencies; residential child care facilities; day and night time care centers; exempt day care centers and Adam Walsh Act Requests must submit the original and one (1) copy of the 1598 to the State Department of Human Resources, Office of Child Protective Services, CA/N Central Registry, 50 Ripley Street, Montgomery, AL 36130. Note: Only Federal Express delivers overnight mail to this physical address. All others request should submit the completed 1598 to their County Department of Human Resources.
Complete the 1598 by printing or typing all information in black or blue ink on the original. Attach additional pages as needed to provide all requested information.
Requesting Person or Agency/Organization Enter the name of the person, agency, or organization requesting the clearance.
Mailing Address Enter the complete mailing address of the person, agency, or organization requesting the clearance.
Telephone Number Enter the telephone number including area code of the person, agency, or organization requesting the clearance.
Email Address (Optional) Enter Email address of the person, agency, or organization requesting the clearance.
PRINT Requestor’s Name PRINT the name of the person, agency, or organization requesting the clearance.
Requestor’s Signature / Date Signature of the person or the agency’s/organization’s designee and the date the 1598 is signed.
Witness Signature / Date Signature of the person witnessing the requestor’s signature and the date the 1598 is signed.
Check All That Apply Enter “X” in the box that indicates the person/agency/organization requesting the clearance. Persons applying to be certified as a provider of Medicaid Rehabilitation services need to enter “X” in the “Medicaid Rehab Provider – DHR Vendor” box. When none of these categories apply, enter “X” in the “Other” box and specify the nature of the business where the person will provide unsupervised care and / or supervision of children.
Employee / Volunteer / Other Select the appropriate category indicating the relationship of the person being cleared to the requesting entity.
Name And Identifying Information Enter the name, sex, race, date of birth, and current mailing address of the person being cleared.
Alias, Maiden & Prior Married Name(s) Enter all aliases, maiden, and prior married names ) for the person being cleared. Enter N/A if not applicable.
