Dhr Ssa Form – Fill Out and Use This PDF

State of Maryland-Child Protective Services Program

CONSENT FOR RELEASE OF INFORMATION/BACKGROUND CLEARANCE REQUEST

INSTRUCTIONS

1.Type or print legibly in ink. INCOMPLETE FORMS WILL BE RETURNED.

2.Submit a separate form for each individual whose name is to be searched.

3.Provide proof of identify and sign Part III in the presence of a Notary Public.

4.This form must be notarized.

5.Return the completed form to either:

Local Department of Social Services in the area where you reside or

Department of Human Resources In-Home Services

Social Services Administration

311 W. Saratoga Street, Room 553 Baltimore, MD 21201

PART I: PURPOSE OF SEARCH: (Complete below and the person that this search pertains to must sign the form on the reverse in part III.)

A. RELEASE TO SELF:

1. To determine if I have been found responsible for indicated or unsubstantiated disposition for a child abuse or neglect investigation.

2. To determine if I have any remaining appeal rights

B. RELEASE TO AN AGENCY/INDIVIDUAL RELATED TO:

	3. Address	City	State	Zip	Telephone

C. RELEASE OF SUMMARY OF AGENCY FINDING:

I am aware that I have an INDICATED disposition following a child abuse or neglect investigation and I authorize the agency to release a summary to the individual/agency identified in part I as to why I was found responsible.

PART II: TO BE COMPLETED IN FULL, BY INDIVIDUAL WHOSE NAME IS BEING SEARCHED

1. IDENTIFYING	Last Name			First	Full Middle		Maiden/Birth Name
INFORMATION:
	Social Security #		Race	Sex	Birthdate	Other Names Used
2.CURRENT ADDRESS				City	State	Zip
3. PRIOR ADDRESS(S) AND DATE(S) (Within The Past 7 Years)				City	State	Zip	Date
				City	State	Zip	Date
4. CURRENT SPOUSE		Last, First, Full Middle			Race	Sex	Birth Date
5. PREVIOUS SPOUSE		Last, First, Full Middle			Race	Sex	Birth Date

6.FULL NAMES OF ALL CHILDREN LIVING WITH YOU (Also include adult children not living with you. Attach additional paper if needed)

Last, First, Full Middle	Race	Sex	Birth Date	Last, First, Full Middle	Race	Sex	Birth Date

DHR/SSA 1279 10/03

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PART III: AUTHORIZATION (Check either 1 or 2 below. )

Pursuant to Maryland Code of Regulation Section 07.02.07.19, pertaining to the confidentiality of Child Protective Services records and reports, I hereby authorize the Maryland Department of Human Resources (DHR):

1. To notify _______________________________ (self, agency, or individual listed in part I) as to whether a local department of

social services has identified me as responsible for “indicated” child abuse or neglect in any record maintained by the Maryland DHR, any Local Department of Social Services, and Child Protective Services.

2. To release a summary of the indicated finding to _____________________________(self, agency, or individual listed in part I).

SIGNATURE: This form must sign in the presence of a Notary Public by the person named in part II. DATE:

PART IV. CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC

City/County of: _______________________________________________ State of: _______________________________

Acknowledged before me this ____________________________ Day of _______________________ 20____

Notary Public

My Commission expires: ______________________

PART V. BACKGROUND CLEARANCE FINDINGS (for Local Department or DHR use only)

1.We are unable to determine at this time if the individual for whom a search has been requested has a CPS finding. Form returned to requesting agency. Date ____________

	2. Sent to DHR or Local Department of Social Services:		Name ______________________________________________
			Date ________________
			Date returned from Local Department _______________________

	3.	Based on information provided by Local Departments of Social Services, we have determined that __________________________ is listed in the
		Central Registry as being responsible for an			Indicated/	Unsubstantiated disposition of	Abuse /	Neglect in reference to an
		investigation conducted in ______________________________. Child Protective Service Case/File/Referral #: ___________________________.
	4.	Holding for Appeal		Appeal Date ___________________________ Appeal Disposition __________________________________

5.Notification sent to Requesting Agency/Individual: Date______________________________

6.Notification sent to Person: Date______________________________

7.Summary Provided: Date __________________________________

8.As of this date, the individual whose name was being searched is NOT identified in the Central Registry as being responsible for abuse or neglect.

DHR/SSA 1279 10/03

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