Form Cfs 717 E PDF Details

In the realm of ensuring the safety and well-being of children, thorough vetting of individuals who will work closely with them becomes paramount. This is where the CFS 717-E, a crucial document spearheaded by the Illinois Department of Children and Family Services, steps in. Designed meticulously to authorize background checks, this form serves as a gateway for evaluating candidates aspiring to join the Child Welfare Direct Service Employee Licensure Board. It demands detailed personal information, including past addresses and any aliases used, to leave no stone unturned in tracing the applicant's history. Beyond just a procedural step, the form delves into the applicant's criminal and child abuse records, accessing data from the Child Abuse and Neglect Tracking System, U.S. Justice Department, Illinois State Police records, and Statewide Child Sex Offender Registry. The information gathered is pivotal for assessing suitability for board membership, emphasizing the gravity of honesty and accuracy in completing the form. It's a binding commitment from the applicant to permit this invasive yet necessary scrutiny, underlining the dedication required to uphold the standards of child welfare services. The declaration that any falsification could be grounds for denial solidifies the serious nature of the application process, ensuring only the most credible individuals are considered for such a critical role. This complex procedure, though rigorous, underscores a shared commitment to protect the most vulnerable, making the CFS 717-E form more than just paperwork; it's a pledge towards safeguarding children's futures.

QuestionAnswer
Form NameForm Cfs 717 E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespursuant, falsification, Attn, pled

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CFS 717-E

 

Illinois Department of Children and Family Services

 

 

 

 

02/01

 

 

AUTHORIZATION FOR BACKGROUND CHECKS

 

 

 

FOR DIRECT CHILD WELFARE SERVICES EMPLOYEE LICENSURE BOARD

 

 

 

PLEASE READ INSTRUCTIONS ON REVERSE SIDE

 

 

 

 

 

 

 

 

PRINT ALL INFORMATION IN INK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL INFORMATION

 

 

 

 

Name (Last, First, Middle)

 

 

 

Maiden and/or Any Names Formerly Used (Last, First, Middle)

 

 

 

 

 

 

(If no other names, write “None”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone Number (Including Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drivers License #

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Address: (Street/Apt.#/City/County/State/Zip Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all previous addresses for the past five years (Street/Apt. #/City/County/State/Zip Code)

 

 

 

 

Dates (From/To)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Age

Place of Birth

 

Citizenship

 

Sex

Height

 

Weight

 

Hair

Eyes

Skin

Race

(Month/Date/Year)

 

 

(County/State)

 

(Country)

 

 

(Ft. In.)

 

(Lbs.)

 

(Color)

(Color)

Tone

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation? If yes, explain below (use additional space on reverse if necessary).

Yes

No

AUTHORIZATION / CERTIFICATION

I AUTHORIZE the Illinois Department of Children and Family Services (DCFS) to conduct the following criminal and child abuse background checks:

•The Child Abuse and Neglect Tracking System to determine whether I have been a perpetrator in an “indicated” incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act.

•U.S. Justice Department and Illinois State Police records to determine whether I have ever been charged with a crime and, if so, the disposition of those charges.

•Statewide Child Sex Offender Registry.

I understand that the child abuse and neglect background check and the criminal history check will be used for considering my candidacy for Board Membership appointment to the Child Welfare Direct Service Employee Licensure Board.

If I am appointed a member of the Child Welfare Direct Service Employee Licensure Board, I further authorize the Department to periodically conduct the above searches during the course of my tenure.

I understand that information obtained as a result of my authorizing these background checks is confidential.

I further certify that the information provided on this form is true and correct.

I acknowledge that falsification of any information provided herein and/or the result of the background checks may be full and sufficient grounds to deny my Board Membership.

Signature

 

Date

 

INSTRUCTIONS FOR COMPLETION

PRINT ALL INFORMATION

In ink.

Name

All current and former names used by the individual must be included. If no other names, write “none.”

Social Security Number

THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY NUMBER.

Address

List current and all addresses, including county and state, where the applicant has lived in the past five years

Identifying Information

All identifying information must be accurate and complete.

Applicant must answer the question, “Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?” If yes, an explanation must be provided, complete with date(s) of the incident(s).

Applicant must sign and date the authorization form.

AUTHORIZATION / CERTIFICATION

Additional space, if needed:

Mail to:

Department of Children and Family Services Division of Training and Development Services Attn: Child Welfare Employee Licensure Program 406 East Monroe, Station 122

Springfield, IL 62701

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