In the realm of child care services, ensuring the safety and well-being of children is of paramount importance. This priority is reflected in thorough background checks for those seeking employment within the sector, a process that is significantly facilitated by the utilization of the HS 2779 form. Known formally as the Child Care Fingerprint Applicant Information & Criminal/Juvenile History Disclosure Form, this document plays a critical role in the recruitment and vetting process. It serves as an initial step for applicants, requiring them to disclose any past criminal or juvenile offenses, alongside a detailed account of their employment history over the past five years. Furthermore, the form mandates the submission of fingerprints for a comprehensive background check, reinforcing the commitment to safeguarding children. Applicants are reminded of the serious consequences of falsifying information on this form, which can lead to criminal prosecution, highlighting the rigorous standards upheld in the child care industry. The form also requires the acknowledgment of potential impacts on employment, based on the outcomes of criminal, juvenile, and abuse registry checks, underscoring the meticulous measures taken to ensure that only those suitable are entrusted with the care of children. Through the essential information it gathers, the HS 2779 form epitomizes the meticulous and cautious approach adopted by child care agencies to foster a secure and nurturing environment for children under their supervision.
| Question | Answer |
|---|---|
| Form Name | Form Hs 2779 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Child_Care_Disc losure_Form 877 862 2425 form |
CHILD CARE
FINGERPRINT APPLICANT INFORMATION
& CRIMINAL/JUVENILE HISTORY DISCLOSURE FORM
Note to Applicant: Failure to answer all the questions may delay your application. Call the Cogent Systems Call Center at
DHS ORI #: TN DHS 000Z
TRANSACTION TYPE - DT
Name of Agency:
Full Provider ID (FEIN) # (including extension / suffix):
Street Address of Agency:
Start Date & Position Verification (information in this box to be completed by the agency director):
Will the duties of the person identified in Part 1
include driving for the agency? Yes |
No |
Prospective Start Date _____/_____/_____
Position:_______________________
I acknowledge that the law requires a fingerprint application to be submitted for this individual and attest that the information within this box is accurate.
_______________________________________
Agency Director Signature |
Date |
Fingerprint Date: ______/______/______
Part 1 Applicant Information:
Last Name _____________________________________
First Name _____________________________________
Full Middle Name_______________________________
Please list any other names you have ever used, including maiden names: _________________________________
______________________________________________
______________________________________________
______________________________________________
Date of Birth ____________________________________
Place of Birth (City, State) __________________________
Social Security Number______________________________
Driver’s License # ________________ State of Issue _____
Home Address __________________________________
City _________________County___________________
State_____________ Zip Code _____________________
Daytime Phone _________________________________
Alternate Phone_________________________________
List work history for the last five (5) years. If you need more space, use a separate sheet of paper.
Employer Name |
From |
To |
Your Position |
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Continued On Back Side
HS 2779 Revised
Part 2 Information for Criminal/Juvenile Records Search:
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Height |
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Weight |
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SSN |
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Circle Codes That Apply |
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Hair Color |
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Eye Color |
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Race |
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Sex |
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Bald |
BAL |
Black |
BLK |
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White |
W |
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Male |
M |
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Black |
BLK |
Blue |
BLU |
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Black |
B |
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Female |
F |
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Blond/Strawberry |
BLN |
Brown |
BRO |
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Asian/Pacific Isl |
A |
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Brown |
BRO |
Gray |
GRY |
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Am. Indian/Alaskan |
I |
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Gray/Part Gray |
GRY |
Green |
GRN |
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Hispanic |
H |
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Red/Auburn |
RED |
Hazel |
HAZ |
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Sandy |
SDY |
Maroon |
MAR |
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White |
WHI |
Pink |
PNK |
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Part 3 Additional Questions:
The penalty for falsification of the information required on this form is criminal prosecution and can result in a jail sentence of up to eleven (11) months and
You must answer the following questions even if your records, including juvenile records, were sealed or otherwise cleared or if anyone, including a judge, law enforcement, or attorney, told you that you no longer have a record.
Have you EVER: |
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1. |
Been arrested, cited, or detained by any law enforcement officer (including military officers)? |
Yes |
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No |
2. |
Been charged with committing any crime or offense as a juvenile or adult? |
Yes |
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No |
3.Been convicted/found to have committed, pled guilty or pled no contest to any
crime or juvenile offense? |
Yes |
No |
4.Been placed in an alternative sentencing or rehabilitative program as a juvenile or adult
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(For example: diversion, deferred prosecution, withheld adjudication)? |
Yes |
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No |
5. |
Received a suspended sentence, been placed on probation, or been paroled? |
Yes |
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No |
6. |
Been in Jail, Prison, or Juvenile or Youth Detention Facility? |
Yes |
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No |
7. |
Been charged with DUI or DWI? |
Yes |
No |
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8. |
Been included on an abuse registry or sex offender registry? |
Yes |
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No |
9. |
Been charged with violation of an order of protection? |
Yes |
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No |
If you answered “YES” to any of questions 1 through 9, you must complete the following table: (if you need more space, use a separate sheet)
Why were you arrested, cited, or charged
Date
Location
Outcome or disposition
I certify, under penalty of law, that the information I have provided is complete and accurate. I authorize the release of any adult criminal or juvenile offense or any abuse registry records, or any information in the records, and any disclosures made in this form, to the agency at which I will be employed and to the Department of Human Services and any person or entity it may designate to assist in the review of my criminal/juvenile or abuse registry history.
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___________________________ |
Applicant Signature |
Date |
Fingerprint Technician Signature (or initials) _________________________________ Date ___________________________
HS 2779 Revised