Form Cfs 717 G – Fill Out and Use This PDF

The CFS 717-G form is an essential document managed by the State of Illinois Department of Children and Family Services, specifically for those seeking licensure as direct service child welfare employees. It encompasses a thorough application process, including personal details, educational background, as well as a series of declarations regarding criminal history, child support compliance, and previous licensure statuses. If you're looking to apply for or renew your child welfare employee license, make sure to accurately fill out and submit this form by clicking the button below.

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Form Cfs 717 G PDF Details

The CFS 717-G form is an integral document for individuals seeking or holding a licensure related to child welfare services in the State of Illinois. Administered by the Department of Children and Family Services (DCFS), this form serves multiple purposes, including the application for Direct Service Child Welfare Employee Licensure, notification of changes in personal information, and declarations regarding criminal history and child support compliance. Applicants provide a wide range of personal information, from basic contact details and educational background to criminal history and other professional licenses held. Additionally, the form inquires about past child abuse or neglect infractions, educational loan defaults, and the specifics regarding any professional disciplinary actions. A distinct checkerbox clearly identifies the application purpose, whether a new application, a change notification, or a re-instatement. Furthermore, signing the document commits the applicant to honesty and compliance with child support orders, underscoring the form's role in ensuring only qualified, responsible individuals are granted licensure to work in child welfare. Applicants are also reminded to report any changes to their name, address, or employer, highlighting the importance of maintaining current records in child welfare employment.

Question	Answer
Form Name	Form Cfs 717 G
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cfs717g illinois child welfare direct service licensure form

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CFS 717-G		REVIEWED BY: ___________________
	State of Illinois
Rev 1/2011		DATE ENTERED: _________________
	Department of Children and Family Services

OFFICE OF CHILD WELFARE EMPLOYEE LICENSURE

Direct Service Child Welfare Employee LicensureApplication

I WORK FOR (check one)

DCFS

POSAGENCY

Other

CHECK HERE IFthis is only notification of CHANGE of agency, name, oraddress.

CYCIS Case Manager ID#			(optional)	DCFS only – Region
						Northern	Central			Southern
Social Security Number						Cook North	Cook Central			Cook South
						Cook North	Cook Central			Cook South

Date of Birth				Agency Name

Name (Last, First, Middle)				Agency Mailing Address (Street Location)

Home Address (Street Location)				City/State/Zip
					,
City/State/Zip			County	Agency Phone			Your Agency E-mail
	,			(	)	-
Home Phone				Supervisor’s Name			Supervisor’s phone & extension
(	)	-					(	)	-	ext.
Home E-mail				Executive Director’s Name

Note: IF YOU ARE ALREADY LICENSED AND ARE REPORTING CHANGES IN THE ABOVE, STOP HERE.

Have you ever been convicted of or have a pending charge for any offenses listed (see below) under the Criminal Code of 1961 listed in the Child Care Act of 1969 [225 ILCS 10/4.2]?

YES

Murder	Home invasion	Armed violence
Solicitation of murder	Vehicular invasion	Felony contributing to the criminal delinquency of a
Solicitation of murder for hire	Criminal transmission of HIV	juvenile
Intentional homicide of an unborn child	Criminal abuse or neglect of an elderly or disabled	Possession of more than 30 grams of cannabis
Voluntary manslaughter of an unborn child	person	Manufacture of more than 10 grams of cannabis
Involuntary manslaughter	Child abandonment	Cannabis trafficking
Reckless homicide	Endangering the life or health of a child	Delivery of cannabis on school grounds
Concealment of a homicidal death	Ritual mutilation	Unauthorized production of more than 5 cannabis sativa
Involuntary manslaughter of an unborn child	Ritualized abuse of a child	plants
Reckless homicide of an unborn child	Offense in any other jurisdiction the elements of which	Calculated criminal cannabis conspiracy
Drug-induced homicide	are similar and bear substantial relationship to any of	Unauthorized manufacture or delivery of controlled
Sex offense under Article11, except offenses described	the foregoing offenses	substances
in Sections 11-7, 11-8, 11-12, and 11-13	Felony aggravated assault	Controlled substance trafficking
Kidnapping	Vehicular endangerment	Manufacture, distribution or advertisement of look-alike
Aggravated unlawful restraint	Felony domestic battery	substances
Forcible detention	Aggravated battery	Calculated criminal drug conspiracy
Harboring a runaway	Heinous battery	Street gang criminal drug conspiracy
Aiding and abetting child abduction	Aggravated battery with a firearm	Permitting unlawful use of a building
Aggravated kidnapping	Aggravated battery of an unborn child	Delivery of controlled, counterfeit, or look-alike
Child abduction	Aggravated battery of a senior citizen	substances to persons under age 18, or at truck stops,
Aggravated battery of a child	Intimidation	rest stops, or safety rest areas, or on school property
Criminal sexual assault	Compelling organization membership of persons	Using, engaging, or employing persons under 18 to
Aggravated criminal sexual assault	Abuse and gross neglect of a long term care facility	deliver controlled, counterfeit, or look-alike
Predatory criminal sexual assault of a child	resident	substances
Criminal sexual abuse	Felony violation of an order of protection	Delivery of controlled substances
Aggravated sexual abuse	Felony unlawful use of weapons	Sale or delivery of drug paraphernalia
Heinous battery	Aggravated discharge of a firearm	Felony possession, sale, or exchange of instruments
Aggravated battery with a firearm	Reckless discharge of a firearm	adapted for use of a controlled substance,
Tampering with food, drug, or cosmetics	Unlawful use of metal piercing bullets	methamphetamine, or cannabis by subcutaneous
Drug-induced infliction of great harm	Unlawful sale or delivery of firearms on the premises of	injection
Hate crime	any school	Felony possession of a controlled substance
Stalking	Disarming a police officer	Any violation of the Methamphetamine Control and
Aggravated stalking	Obstructing justice	community Protection Act.
Threatening public officials	Concealing or aiding a fugitive

College attended

Degree

Year completed

Are you in default of an educational loan?	YES	NO

Have you ever been the perpetrator of an indicated child abuse/neglect report?	YES	NO

Are you currently the subject of a child abuse/neglect investigation?	YES	NO

Have you ever been convicted of perjury or falsification of anything in a case file?	YES	NO
If so please attach a written explanation/resolution.	YES	NO
If so please attach a written explanation/resolution.

Re-instatement application only: Indicate specific reasons for your request to reinstate your license (use separate paper if necessary and attach supportive documentation as appropriate).

List below any other type of professional license/certification(s) you have ever held, including any held outside

Type

License/Certificate No.

Has the above license(s) ever been denied, suspended, revoked, or the subject of disciplinary action by any jurisdiction?

If the answer to the above question is YES, please attach a written explanation and verification of resolution.

YES

•I certify, under penalty of perjury, that I am not more than 30 days delinquent in complying with a child support order.

•I understand that failure to so certify will result in delay of this license pending resolution of the delinquency

•I understand that making a false statement regarding my child support status may subject me to contempt of court.

Signature

Date

•I, the undersigned hereby apply for a CWE license in accordance with Part 412 "Licensure of Direct Child Welfare Service Employees and Supervisors".

•I affirm that the information provided herein is true and complete.

•I understand that making false statements to obtain a child welfare employee license is grounds for licensure action under Rule 412, up to and including suspension or revocation of the license.

•I hereby give permission for my license status to be given upon request to my employer or prospective employer and others as per Rule 412.

•I understand that I must keep the Office of direct service Child Welfare Employee Licensing apprised of changes to my name, address, and employer and that failure to do so could result in licensure action up to and including revocation.

Signature

Date

APPLICATION-CHECKLIST

1.	I HAVE BEEN FINGERPRINTED RECENTLY?	Yes	No

2.	I HAVE REQUESTED MY TRANSCRIPT FROM COLLEGE SHOWING MY DEGREE?	Yes	No
	(IF HIRED After JUNE 1, 2001 an original must be submitted to the address below directly from your school.)	Yes	No


3.	IF NEW POS EMPLOYEE: I HAVE COMPLETED the CFS-718E WITH MY EMPLOYER?	Yes	No
	(The CFS-718E is for the Central Office of Licensing under Rule 401)	Yes	No

4.I HAVE ATTACHED ALL REQUIRED EXPLANATIONS (as needed).

Yes

SEND THIS COMPLETED FORM with the CFS-717F to:

FAXES WILL NOT BE ACCEPTED.

IDCFS OFFICE OF CHILD WELFARE EMPLOYEE LICENSURE 406 East Monroe – Station #122, Springfield, IL 62701

Questions ----

call 217-782-2851

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1. The Form Cfs 717 G needs particular information to be entered. Be sure the following fields are complete:

2. Once your current task is complete, take the next step – fill out all of these fields - CYCIS Case Manager ID optional, Agency Name Agency Mailing Address, Note IF YOU ARE ALREADY LICENSED, Have you ever been convicted of or, YES, Murder Solicitation of murder, in Sections and, Kidnapping Aggravated unlawful, Home invasion Vehicular invasion, person, Child abandonment Endangering the, are similar and bear substantial, Armed violence Felony contributing, juvenile, and Possession of more than grams of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Form Cfs 717 G conclusion process described (stage 2)

3. The following segment will be about College attended, Degree, Year completed, Are you in default of an, Have you ever been the perpetrator, Are you currently the subject of a, Have you ever been convicted of, YES, YES, YES, YES, Reinstatement application only, List below any other type of, Type, and Type - fill out all of these blank fields.

Form Cfs 717 G writing process outlined (step 3)

4. To go onward, this next section involves filling in a handful of empty form fields. Examples include APPLICATIONCHECKLIST, I HAVE BEEN FINGERPRINTED RECENTLY, I HAVE REQUESTED MY TRANSCRIPT, IF NEW POS EMPLOYEE I HAVE, I HAVE ATTACHED ALL REQUIRED, Yes, Yes, Yes, Yes, SEND THIS COMPLETED FORM with the, IDCFS OFFICE OF CHILD WELFARE, East Monroe Station Springfield, and Questions call, which you'll find vital to carrying on with this particular form.

APPLICATIONCHECKLIST, IDCFS OFFICE OF CHILD WELFARE, and Yes of Form Cfs 717 G

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Form Cfs 717 G – Fill Out and Use This PDF

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