South Carolina Department of Social Services
Child Care Licensing
DIRECTOR/STAFF EVIDENCE OF NON-CONVICTION
AND STATEMENT OF COMPLIANCE
This form must be completed by all persons applying for employment with, or employment by, or seeks to provide caregiver services in, or is a caregiver at a child care facility. Keep a copy for your facility file.
The South Carolina Child Care Licensing Law, Section 63-13-40 D(1) et seq., Code of Laws states, “To be employed by or to provide caregiver services at a childcare facility licensed, registered, or approved under this sub-article, a person first shall undergo a state fingerprint-based background check to be conducted by the State Law Enforcement Division (SLED) to determine any state criminal history, a fingerprint-based background check to be conducted by the Federal Bureau of Investigation to determine any other criminal history, and a Central Registry check to be conducted by the department to determine any abuse or neglect perpetrated by the person upon a child. (2) However, a person may be provisionally employed or may provisionally provide caregiver services after the favorable completion of the State Law Enforcement Division name and date of birth-based background check until such time as the SLED and Federal Bureau of Investigation fingerprint-based background check, and the Central Registry check are completed if the person executes a sworn statement on a form provided by the department that he or she has not been convicted of any crime enumerated in this section and that he or she is not on the Central Registry for having perpetrated abuse or neglect upon a child.”
This questionnaire and certification is deemed to be continuous in nature, and any future violation or non-compliance with the applicable statute herein must be reported immediately to DSS Child Care Licensing.
I have read and become familiar with S.C. Code Section 63-13-40 (as amended), which provides the requirements for employment in a childcare facility.
I affirm that I am an employee, employer, or seeking employment in a childcare facility, and that I am in compliance with the provisions of S.C. Code Section 63-13-40 (as amended).
I understand that if I am found to be in violation of S.C. Code Section 63-13-40 (as amended), such non-compliance will affect the issuance or status of the licensure/approval/registration of this facility.
I understand, that in accordance with the requirements of S.C. Code Section 63-13-40 (C) (as amended) that all application forms provided for employment at a childcare facility must include, at the top of the application form in large bold type, a statement indicating that a person who has been convicted of a crime enumerated in Subsection (A) who applies for employment with, is employed by, or seeks to provide caregiver services in, or is a caregiver at such a facility, is guilty of a misdemeanor, and, upon conviction, must be fined not more than five thousand dollars, or imprisoned not more than one year, or both.
Name: (Please print)
Address:
Facility Name:
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I AFFIRM TO THE ABOVE NON-CONVICTION AND STATEMENT OF COMPLIANCE. |
Staff’s Signature: |
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Staff’s Title: |
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SWORN TO AND SUBSCRIBED BEFORE ME |
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This |
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day of |
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Notary Public for South Carolina
My Commission Expires:
