STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
CHILDREN’S ADMINISTRATION
500 First Avenue South, Suite 501
Seattle, Washington 98104-9968, Fax 1-206-341-7930
E-mail CANhistorychecks@dshs.wa.gov
In-State Child Abuse and Neglect Founded Findings Request
The information provided through this service is limited to the existence of founded findings (substantiated findings) of allegations of child abuse and neglect, and complies with the Adam Walsh Child Protection and Safety Act of 2006 for purposes of approving a prospective adoptive or foster parent.
Instructions: This form must be typewritten and signed. Any handwritten or incomplete forms will be returned for correction.
1.Complete one form for each individual for whom a child abuse/neglect findings request is being requested.
2.Mail completed requests to: DSHS Children’s Administration CA/N History Checks
500 First Avenue South, Suite 501
Seattle WA 98104-9968
3. Or fax completed requests to 1-206-341-7930 or e-mail to CANhistorychecks@dshs.wa.gov
A. Requestor Information
NAME, LAST |
FIRST |
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AGENCY NAME AND REQUESTOR’S TITLE |
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MAILING ADDRESS |
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CITY |
STATE |
ZIP CODE |
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TELEPHONE NUMBER (WITH AREA CODE) |
FAX NUMBER (WITH AREA CODE) |
E-MAIL ADDRESS |
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B. Signature of Requestor
REQUESTED BY (SIGNATURE) |
DATE SIGNED |
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C. Subject of Records Requested
NAME: LAST |
FIRST |
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MIDDLE |
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DATE OF BIRTH |
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PREVIOUS NAMES USED (AKA, ALIASES OR MAIDEN) |
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SEX |
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SOCIAL SECURITY NUMBER |
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LAST WASHINGTON STATE MAILING STREET ADDRESS |
CITY |
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STATE |
ZIP CODE |
D. Authorization
By signing below, I authorize the State of Washington Department of Social and Health Services to release confidential information about me regarding any founded findings of child abuse or neglect to the requesting individual or agency identified above.
SUBJECT’S SIGNATURE |
DATE SIGNED |
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Response by the Washington State DSHS Children’s Administration
The result of a search of the Children’s Administration child welfare records, pursuant to the data provided above is as follows:
Our records do not indicate that the person identified in your inquiry request has been named as a subject in a founded finding of abuse or neglect.
Our records indicate that one or more founded findings exist in which the person identified in your inquiry request was the subject.
STAFF INITIALS / DATE
Completed request forms must be typewritten and mailed to the address above. Call 1-800-562-5624 or e-mail
CANhistorychecks@dshs.wa.gov with any questions.
DSHS 23-032 (REV. 12/2013)
Instructions
Purpose
The information provided through this service, and with this form, is limited to the existence of founded findings of child abuse and neglect. “Inconclusive” or “unfounded” findings, or other information contained in the individual’s record, will not be provided through this process. If you are seeking information for purposes other than placement or an adoptive pre or post-placement report, you must request the records through the local child welfare office. You must use this form if you are (1) a public child welfare agency, (2) a private agency with the authority to place children, or 3) an individual approved by the court, under Washington chapter 26.33 RCW, to complete an adoption pre-placement or post-placement report, to obtain information from Washington State Department of Social and Health Services (DSHS) about the history of founded allegations of Child Abuse and Neglect for placement purposes.
Use
You must type information on this form and the signatures must be handwritten. Use the tab key to move between fields. “Requestor” refers to the person or agency who is requesting the record. The “Authorization” signature is the signature of the person whose records will be reviewed for child abuse and neglect history. A separate form must be completed for each person whose records are requested.
Parts of Form
A.Requestor Information
•Name: Provide the full name of the person requesting the information. This should be an employee of a private or public child welfare agency or a person who is authorized to complete an adoption pre-placement or post-placement report under chapter
26.33RCW.
•Agency’s Name and Requestor’s Title: Provide the name of the agency and title of the employee of the private or public child welfare agency requesting the information. If you are an individual approved to complete adoption pre-placement and post- placement reports, state “adoption home study investigator.”
•Mailing Address: Provide the mailing address of the agency or business requesting the information.
•Telephone Number: Provide the telephone number for the agency or business requesting the information, include the area code.
•Fax Number: Provide the fax number for the agency or business requesting the information, include the area code.
•E-Mail Address: Provide the agency e-mail address for the person requesting the information.
B.Signature of Requestor
•Requested By (Signature): The person requesting the information must sign the document.
•Date Signed: The person requesting the information must include the date that the document was signed.
C.Subject of Records Requested
•Name: Provide the full name of the individual whose records you are requesting to be checked.
•Last Washington State Mailing Street Address: If the individual no longer lives in Washington, please provide the last Washington State mailing address for the individual whose records you are requesting to be checked. If the individual is still a resident of Washington State, provide his or her current Washington State mailing address.
•Date of Birth: Provide the date of birth of the individual whose records you are requesting to be checked.
•Previous Names Used (AKA, Aliases or Maiden): Provide any other names known to be used by the individual whose records you are requesting to be checked.
•Social Security Number: Provide the social security number of the individual whose records you are requesting to be checked.
D.Authorization
•Signature: The individual whose records you are requesting must sign the document, unless you are otherwise authorized under law to receive this confidential information.
•Date Signed: The individual whose records you are requesting must include the date that he/she signed the document.
•If you believe that you have independent legal authority to receive this confidential information without a signed authorization of the individual whose information you are requesting you must attach a copy of the court order, other documentation and/or explanation of the legal basis for your authority to obtain this confidential information. Children’s Administration will make an independent determination based on the information you provide and the applicable state and federal laws whether you are legally authorized to obtain this information.
DSHS 23-032 (REV. 12/2013)
