Dhr Chc 2178 Form – Fill Out and Use This PDF

DHR CRIMINAL HISTORY CHECK APPLICATION

Part 1 of 2

DHR FEE PAID

Mail Application (Parts 1 & 2) and Fingerprint Cards to:

Alabama Department of Human Resources

Office of Criminal History

P.O. Box 304000

Montgomery, Alabama 36130-4000

(334) 353-5400

Type or print legibly

Address:

City:			State:			Zip Code:
Date of Birth:			Race:			Sex:
	Employment	Home Study		Household Members	License/Approval		Therapeutic Programs	Volunteer Work
	❑ Adult Day Care	❑ DHR Adoption		❑ DHR Adoption	❑ Adult Day Care		❑ Foster Care	❑ Board Member
	❑ Child Placement Agency	❑ ICPC		❑ Foster Care	❑ Day Care Center		❑ Mental Health Services	❑ DHR
Applying	❑ Day Care Center	❑ Private Adoption		❑ Home Day Care	❑ Elder Care		❑ Relative Placement	❑ Internship
For:	❑ DHR ❑ DHR Other	❑ Relative Placement		❑ Private Adoption	❑ Foster Care		❑ Other	❑ Other
	❑ Elder Care	❑ Other		❑ Relative Placement	❑ Home Day Care
(CHECK
	❑ Foster Care			❑ Other	❑ Other
ONE)	❑ Health Services
	❑ Home Day Care
	❑ Preventive Services
	❑ Residential Care Agency
	❑ Other

Affidavit For Release of Information

I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Alabama Department of Human Resources, DPS/ABI and their officers and agents from any and all claims, actions, or causes of action, which may arise as a consequence of the release of the criminal history information.

I am possessed of sound mind and legally competent to execute this release. I hereby authorize the Alabama Department of Human Resources, DPS/ABI to release any and all criminal history information.

I certify that I have read this release and that I understand the significance of the same and in witness thereof I have voluntarily

signed my name on this __________________ day of ________________________________ 20 __________ .

Signature: __________________________________________________________

*NOTE* This document must be witnessed by two persons or notarized by a Notary Public.

DHR-CHC-2178 Revised August 2010

DHR CRIMINAL HISTORY CHECK APPLICATION

Part 2 of 2

Name of Requesting Agency: __________________________________________________________________________________________________

(employer, adoption agency, foster home licensing agency, child or adult care center, volunteer coordinating agency, etc.)

Address: ________________________________________________________________________________________________________________________________

Telephone No: ______________________________________ DHR Licensing or Approving Office: ____________________________________________________

MANDATORY CRIMINAL HISTORY CHECK NOTICE: Alabama law requires that a criminal history background check be conducted on applicants for certain DHR positions and on all persons who hold a license or work in a Department of Human Resources licensed child care or adult care home, a foster or adoptive home approved by the Department of Human Resources, or a licensed child placing agency, including all officers and agents of the entity. You are required to provide full, accurate and complete information on your criminal conviction history upon application for a license or employment. This information shall be used to determine your suitability to provide care for children, the elderly, or disabled individuals. Unless a criminal history background check and suitability determination have previously been obtained, you must complete a DHR Criminal History Check Application (Parts 1 & 2) with fingerprints at the time of application for employment. Refusal to complete these documents or providing false information shall result in refusal of employment, approval, or licensure. The term conviction includes a determination of guilt by a trial, by a plea of guilty, or a plea of nolo contendere. Any individual determined to have submitted false information will be referred to the district attorney or law enforcement for investigation and possibly prosecution. An individual who intentionally falsifies any information on a statement is guilty of a class A misdemeanor, punishable by a fine of not more than two thousand dollars ($2,000) and imprisonment for not more than one year.

Convictions for any of the following crimes shall make an individual unsuitable for approval related to employment, adoption, foster home licensure, child or adult care licensure, or volunteer work:

1.Murder, manslaughter, or criminally negligent homicide.

2.A sex crime.

A sex crime includes the following:

a)Enticing a child to enter a vehicle, room, house, office, or any other space for immoral purposes, as proscribed by Section 13A-6-69 of the Code of Alabama 1975.

b)Incest, when the offender is an adult and the victim is a minor, as proscribed by Section 13A-13-3 of the Code of Alabama 1975.

c ) Kidnapping of a minor, except by a parent, in the first or second degree, as proscribed by Section 13A-6-43 or Section 13A-6-44 of the Code of Alabama 1975.

d)Promoting prostitution in the first degree or second degree, as proscribed by Section 13A-12-111 or Section 13A-12-112 of the Code of Alabama 1975.

e)Rape in the first or second degree, as proscribed by Section 13A-6-61 or Section 13A-6-62 of the Code of Alabama 1975.

f ) Sexual misconduct, as proscribed by Section 13A-6-65 or the Code of Alabama 1975.

g)Sexual torture, as proscribed by Section 13A-6-65 of the Code of Alabama 1975.

h)Sexual abuse in the first or second degree, as proscribed by Section 13A-6-66 or Section 13A-6-67 of the Code of Alabama 1975.

i )	Sodomy in the first or second degree, as proscribed in Code 13A-6-63 or Section 13A-6-64 of the Code of Alabama 1975.
j )	Soliciting a child by computer for the purposes of committing a sexual act and transmittal of obscene material to a child by
	computer as proscribed by Sections 13A-6-110 and 13A-6-111 of the Code of Alabama 1975.

k)Violation of the Alabama Child Pornography Act, as proscribed by Sections 13A-12-191, 13A-12-192,13A-12-196, or 13A-12-197 of the Code of Alabama 1975.

l ) Any solicitation, attempt, or conspiracy to commit any of the offenses listed in paragraphs a. to k., inclusive.

m)A crime listed in the Community Notification Act, Chapter 20 of Title 15 of the Code of Alabama 1975.

3.A crime that involves the physical or mental injury or maltreatment of a child, the elderly, or an individual with disabilities.

4.A crime committed against a child.

5.A crime involving the sale or distribution of a controlled substance.

6.Robbery.

7.Conviction for a violation or attempted violation of an offense committed outside the State of Alabama for a sex crime or any other crime if the offense would be a crime in Alabama.

Criminal History Statement

Have you ever had a suitability determination made by the Department of Human Resources in connection with a previous

criminal history check? Yes (___) No (___) If yes, send the form to DHR.

Have you ever been convicted of a crime? Yes (___) No (___) If yes, state on the lines below the date, crime, location, punishment imposed, and whether the victim was a child, elderly or a disabled individual.

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Signature: ________________________________________________________________________________Date:____________________________________

Print Name: ________________________________________________________________________________________SSN# __________________________________

DHR-CHC-2174 Revised April 2010