DCYF 23-032: In-State Child Abuse and Neglect Founded Findings Request

“Requestor” refers to the person or agency who is requesting the record. Name: Provide the full name of the person requesting the information.

This should be an employee of a private or public child welfare agency, a person who is authorized to complete an adoption pre-placement or post-placement report under chapter 26.33 RCW, an employer or agency required by law to check any child abuse and neglect registry maintained by Washington state, or the individual submitting a self-request.

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.” For self-requests required in order to have unsupervised access to children, provide the position you are seeking and the agency or business requiring this information.

Mailing Address: Provide the mailing address of the agency or business requesting the information or your information if you wish results sent back to you. Telephone Number: Provide the telephone number for the agency or business requesting the information, include the area code or your number if self-requesting. 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 or your e-mail address if self-requesting and you wish results sent to you.

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.

Name: Provide the full name of the individual whose records you are requesting to be checked. If you are self-requesting, provide your name as instructed.

Date of Birth: Provide your date of birth or of the individual whose records you are requesting to be checked. Previous Names Used (AKA, Aliases or Maiden): Provide any other names you have used or 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. The social security number of the individual whose records you are requesting is optional and assists in the proper identification of an individual's records.

Last Washington State Mailing Street Address: If the individual no longer lives in Washington, please provide the last Washington State mailing address of the individual whose records are requested to be checked. If the individual is still a resident of Washington State, provide his or her current Washington State mailing address.

By signing, I authorize the State of Washington Department of Children, Youth, and Families to release confidential information about the existence of any founded findings of child abuse or neglect to the requesting individual or agency.

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 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.

E-mail to CANhistorychecks@dcyf.wa.gov, or fax completed requests to 206-341-7930, or mail completed requests to: Department of Children, Youth, and Families CA/N History Checks P.O. Box 40993 Olympia, WA 98450