Form CFS 718-B PDF Details

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QuestionAnswer
Form Name Cfs 718 B Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names dcfs 718, illinois check form, cfs 718 b, illinois daycare action form

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CFS 718-B

Rev 12/2015

 

 

 

Illinois Department of Children and Family Services

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION FOR BACKGROUND CHECK for Child Care

 

 

 

 

 

READ INSTRUCTIONS ON REVERSE SIDE AND PRINT ALL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ONE BOX IN EACH COLUMN IN EITHER ROW A or B:

 

 

 

 

 

 

 

Category of Facility

 

 

Specific Type of Application

 

Person in the Home/Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant

 

 

 

 

 

Child Care in the Home

 

 

Unlicensed Day Care Home

 

Member of Household (ages 13 to 17)*

 

 

 

 

 

 

 

 

*Parent/Guardian signature required

 

 

A

 

 

Unlicensed/Licensed/

 

 

Day Care Home

 

1

 

 

 

 

 

 

Member of Household (age 18 and over)

 

 

 

Applying for

 

 

Group Day Care Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee/Volunteer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ward

 

 

 

 

 

Child Care Facility

 

 

Youth Emergency Shelter

 

Applicant/Operator (Person applying to operate

 

 

 

 

 

(other than a home)

 

 

Child Welfare Agency

 

a licensed child care facility)

 

 

 

 

 

 

 

Group Home

 

 

 

B

 

 

Exempt/Licensed/

 

 

Day Care Center

 

Executive Director

 

 

 

 

 

 

 

Child Care Institution/Maternity Center

 

 

 

 

 

 

 

Applying for

 

 

Day Care Agency

 

Employee/Volunteer

 

 

 

 

 

 

 

License Exempt Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL INFORMATION (Please see additions instructions on the back page)

2

Last Name/First Name/Middle Initial

Social Security or ITIN Number

Maiden and/or Any Names Formerly Used (Last/First/Middle Initial)

 

 

 

 

 

 

__ __ __ - __ __ - __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all previous addresses for the past five (5) years,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

including those outside of Illinois.

 

 

 

 

 

 

Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street/Apt.#/City/County/State/Zip Code)

 

 

 

 

 

From/To

CURRENT ADDRESS, TELEPHONE (when applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/Apt.#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State:

__ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code: __ __ __ __ __

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone ( __ __ __ )

__ __ __ - __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell Phone ( __ __ __ )

__ __ __ - __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you lived outside of Illinois in the past 3 years?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

Age

 

Place of Birth

 

Citizenship (Country)

Gender

 

Height

Weight

 

 

Hair

 

Eye

 

 

(Month/Date/Year)

 

 

 

 

(City and State)

 

USA

 

M

 

Ft. In.

(lbs.)

 

 

(color)

 

(color)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

-

 

 

 

 

 

 

 

 

Other Specify

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race (Check all that apply)

 

 

 

 

 

 

 

 

 

Ethnicity

 

Native American/Alaskan (Indian or Eskimo)

Black/African American

White

Declined to Identify

 

(see codes on Page 2)

 

 

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

Unknown

Could not be Verified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION /CERTIFICATION

 

Have you ever been indicated as perpetrator in a child abuse/neglect investigation?

 

Yes

No

 

Have you ever been convicted of a criminal offense, other than a minor traffic violation?

 

Yes

No

 

I certify that I have read and understood the Authorization/Certification box on the back page of this form.

 

 

 

 

 

 

 

 

3

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Signature (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED BY SUPERVISING AGENCY

 

 

 

 

 

 

 

 

 

This authorization will not be processed without completion of this section. The licensing representative or child’s worker must complete the following

 

Date Fingerprinted:

 

 

 

 

 

 

 

Supervising Agency Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

Or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider ID #

 

 

 

 

 

 

 

 

DCFS Region/Site/Field

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Worker

Worker ID#/Phone Number

 

City

IL ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor

Supervisor ID#/Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BACKGROUND RESULTS AS APPLICABLE

 

 

 

 

 

 

FOR CENTRAL OFFICE OF LICENSING USE

 

Sex Offender Clearance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANTS Clearance:

 

 

 

 

 

 

 

 

 

SID#

 

 

Clear

 

 

Record

 

 

5

 

 

 

 

 

 

 

BC-03 Registered:

 

 

 

 

 

 

 

 

 

 

 

 

Illinois State Police Clearance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FBI Clearance:

 

 

 

 

 

 

 

 

 

FBI Sent Out:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transfer Clearances: SO/CANTS:

 

 

ISP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO SHOULD USE THIS FORM: This form must be completed by every person age 13 or older as part of an application to operate or reside in a child care facility, or be employed by or volunteer at a day care or group day care home. Every person subject to a background check must complete the first three sections identifying the type of facility and what role they will have at the facility and all personal information. All identifying information must be accurate and complete. The Parent or Guardian’s signature is required if background check is for a minor.

 

ADDITIONAL INSTRUCTIONS FOR SECTIONS 2 AND 3 OF THE FRONT PAGE

 

 

Name:

Current and all former names used by the individual must be included. If no other names, write “none.”

 

 

Social Security,

THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY, INDIVIDUAL

ITIN or Assigned #.

TAXPAYER IDENTIFICATION (ITIN) NUMBER OR DEPARTMENT ASSIGNED NUMBER

 

 

Address:

Current and all addresses, including county, where the person has lived in the past five years (Indicate if outside of Illinois)

 

 

 

 

 

Race:

Enter all race codes that apply.

 

 

 

 

NA

=

Native American/Alaskan (Indian or Eskimo)

WH

=

White

 

AO

=

Asian

UK

=

Unknown

 

BL

=

Black/African American

DI

=

Declined to Identify

 

PI

=

Native Hawaiian/Pacific Islander

CV

=

Could not be Verified

 

 

 

 

 

Ethnicity:

Enter the primary Ethnicity

 

 

 

 

NH

=

Not Hispanic (NONE)

HA

=

Hispanic Central American

 

HS

=

Hispanic South American

HN

=

Hispanic Dominican

 

HM

=

Hispanic Mexican

HO

=

Hispanic Other

 

HP

=

Hispanic Puerto Rican

UK

=

Unknown

 

HD

=

Hispanic Spanish Descent

DI

=

Declined to Indentify

 

HC

=

Hispanic Cuban

CV

=

Could not be Verified

 

 

 

 

 

 

 

ADDITIONAL INSTRUCTIONS FOR SECTIONS 4 OF THE FRONT PAGE

Instruction for Left Side -

Name of Facility:

The full name which appears on the license application or the

 

license. (DO NOT USE ACRONYMS)

Provider ID #:

The Provider ID. (The number which appears on the license

 

certificate for the facility. Initial Applications will be assigned #

 

by Background Check Unit.)

Street/City/Zip:

The site of licensed facility where person is licensed or

 

employed.

Instructions for Right Side –

Supervising Agency:

Print the name and Provider ID# of Agency which

 

will supervise the facility

Provider ID #:

 

DCFS Region/Site/field:

The DCFS Region/Site/Field.

Name of the

 

Worker:

Name, ID and phone of the worker

Name of the

 

Supervisor:

Name, ID and phone of the supervisor

The Authorization for Background Check must be submitted to the worker for completion of Section 4 and for forwarding to the DCFS pertinent Background Check Unit. The worker must check the form for completeness and accuracy, confirm that the person (if age 18 or older) has been fingerprinted, and verify the correct spelling of names alongside a form of identification, such as a driver’s license or photo ID.

AUTHORIZATION/CERTIFICATION

I authorize the Illinois Department of Children and Family Services to conduct an investigation to determine whether I have ever been charged with a crime and, if so, the disposition of those charges. I authorize the Department to request information and assistance from the U.S. Justice Department and the Illinois Department of Law Enforcement in the conduct of this investigation. I authorize the Department to periodically search child abuse and neglect reports to determine whether I have been a perpetrator of an “indicated” incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act. The child abuse and neglect background check and the criminal history investigation may be used for considering an application for license, current or prospective employment, or service as a volunteer in a child care facility. Persons 13-17 years of age signing this form authorize a search of CANTS and LEADS only and are not subject to fingerprinting.

I understand that information obtained as a result of my authorizing this investigation is confidential but may be shared with my employer, prospective employer, the licensing applicant for whom my background check is required or with authorized licensing staff in accordance with applicable state and federal law and DCFS Regulations. I further certify that the information provided on this form is true and correct. I acknowledge that falsification of any information provided above and/or the results of the background check may be full and sufficient grounds to deny the application for licensure or may result in the termination of my employment.

Should you feel that the information on your Illinois State Police record or Federal Bureau of Investigation record is incorrect you may visit: http://www.ilga.gov/commission/jcar/admincode/020/02001210sections.html for the ISP and http://www.fbi.gov for FBI.

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