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.

QuestionAnswer
Form NameForm Cfs 717 G
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescfs717g 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NO

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.

 

 

 

 

 

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

Type

Type

License/Certificate No.

License/Certificate No.

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

NO

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.)

 

 

 

 

 

 

 

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)

 

 

 

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

Yes

No

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:

Completing part 1 of Form Cfs 717 G

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

Always be very attentive when filling out APPLICATIONCHECKLIST and IDCFS OFFICE OF CHILD WELFARE, since this is the part where a lot of people make some mistakes.

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