Form Dphhs Qad Crl 18 PDF Details

In the quest to ensure the safety and well-being of individuals receiving care, the Department of Public Health and Human Services (DPHHS) in the State of Montana requires a comprehensive background check for all adult and youth care facility providers. This necessity is embodied in the DPHHS-QAD/CRL-18 form, a document designed to facilitate the release of information crucial for conducting criminal, protective service, and motor vehicle background checks. At its core, the form collects personal information from the applicant, including current and past residences, to ascertain if living in different states or on Indian reservations might necessitate additional background checks at the applicant's expense. Importantly, the form serves not just as a tool for gathering data but as a conduit through which applicants authorize DPHHS to procure and relay sensitive information to care facilities or their representatives. This authorization covers any records that could reflect negatively on an individual’s suitability as an employee or volunteer, spanning substantiated reports of child abuse or neglect, criminal history, and motor vehicle records. Furthermore, the form underscores the consequences of inaccuracies or omissions, which can lead to the denial of the application. Yet, while it facilitates the sharing of confidential information, DPHHS signifies through this form that it cannot guarantee the maintenance of this confidentiality once the information is passed on. This dual role of the DPHHS-QAD/CRL-18 form, as both a protective measure and a potential legal liability, highlights the delicate balance between personal privacy and public safety in the domain of care provision.

QuestionAnswer
Form NameForm Dphhs Qad Crl 18
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescrl018 dphhs release of information

Form Preview Example

DPHHS-QAD/CRL-18 (Revision 3-10)

DEPARTMENT OF

PUBLIC HEALTH AND HUMAN SERVICES

STATE OF MONTANA

- RELEASE OF INFORMATION -

For Adult and Youth Care Facility Providers

Criminal / Protective Service / Motor Vehicle

Background Checks

PERSONAL INFORMATION

Section A – Current Information

Phone # ________________________

Legal Name: ______________________________________________________________________________________

(First)(Middle)(Maiden)(Last)

Aliases/Other Names Used: __________________________________________________________________________

Residential Address: ________________________________________________________________________________

(Street)(City) (State ) (Zip)

Mailing Address: ___________________________________________________________________________________

 

 

 

 

 

 

(Street)

 

 

(City)

(State )

(Zip)

 

 

Sex: [

] Male

[ ] Female

Date of Birth: _________________

Social Security #_________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B – Past Residences

 

 

 

 

 

 

 

 

 

 

 

 

Within the last five (5) years, have you…

 

 

 

 

 

 

 

 

1.

…lived in another state?

 

 

 

 

[

] Yes

[

] No

 

 

2.

…lived on or do you now live in an area designated as an Indian reservation?

[

] Yes

[

] No

 

 

 

If you answered yes to the any of the above questions:

 

 

 

 

 

 

 

 

 

 

Please state where you have lived since turning 18 in the table below.

 

 

 

 

 

 

 

 

You will need to obtain an out of state background check or a tribal background check at your cost.

 

 

 

 

City

 

 

 

County

 

Reservation

State

Dates of Residency (From – To)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D – Employment Status

The facility that I am working / living at is:

Director Name / Facility Name: ___________________________________________________________________

Facility Mailing Address: ________________________________________________________________________

PLEASE COMPLETE BOTH SIDES OF THIS FORM

Section E – Authorization Statement and Signature

I, ____________________ (applicant name), am aware that __________________________________ (provider or its

authorized representative), has requested confidential information from the Montana Department of Public Health and Human Services, in accordance with 41-3-205(3)(o), MCA as part of a review of my personal background in connection with my status as a current or prospective employee of or volunteer for that entity.

I am aware that CFSD, DMV, and DOJ records may contain information that could adversely affect my employment or volunteer status and/or approval as outlined in ARM 37.95.161 and ARM 37.95.176. These records will relate to any substantiated report(s) of child abuse or neglect in Montana, criminal history records, and motor vehicle records. As a household member, I understand that I am also subject to the above requirements.

I am also aware that although the entities or individuals requesting and receiving confidential CFSD information are bound by law or agreement with DPHHS to protect or preserve its confidential nature, DPHHS has no ability or authority to ensure that confidentiality is maintained after this information is released by DPHHS.

In full acknowledgement of the above information and notice, I authorize CFSD to provide the requested confidential information to__________________________________________ (provider or its authorized representative), and I

hereby also release CFSD from any claims or causes of action which may subsequently arise from release of this confidential information.

NOTE: Any deletions or oversights may result in the denial of your application.

Signed: _______________________________________________________________ Date: ____________________

(To be signed in front of a notary)

TO BE COMPLETED BY A NOTARY PUBLIC:

Taken, sworn, and subscribed before me this ____________ day of _________________________ A.D. ____________

_________________________________________________________

Notary Public for the State of Montana

Residing at: _______________________________________________

My commission expires: _____________________________________

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This form will involve specific details; in order to ensure consistency, you need to take note of the next suggestions:

1. You need to fill out the Form Dphhs Qad Crl 18 properly, thus be careful while working with the segments that contain all of these blanks:

Stage number 1 of filling out Form Dphhs Qad Crl 18

2. Once the last section is completed, go to type in the suitable details in all these - Dates of Residency From To, Section D Employment Status The, Director Name Facility Name, Facility Mailing Address, and PLEASE COMPLETE BOTH SIDES OF THIS.

Dates of Residency From To, Director Name Facility Name, and Section D Employment Status The of Form Dphhs Qad Crl 18

3. Completing Section E Authorization Statement, I am aware that CFSD DMV and DOJ, I am also aware that although the, and In full acknowledgement of the is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part number 3 for completing Form Dphhs Qad Crl 18

4. All set to complete this fourth form section! In this case you'll have all of these Signed Date, To be signed in front of a notary, TO BE COMPLETED BY A NOTARY PUBLIC, Taken sworn and subscribed before, Notary Public for the State of, Residing at, and My commission expires form blanks to fill out.

Part # 4 in submitting Form Dphhs Qad Crl 18

As for TO BE COMPLETED BY A NOTARY PUBLIC and My commission expires, make sure you double-check them in this section. These two could be the most important ones in this form.

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