The provider's Authorized Person must complete this form and email or fax it to the Justice Center.
Results: the Authorized Person will receive an email indicating the results of the SEL check.
Oversight Agency: check one: OMH, OPWDD, DOH, SED, OASAS or OCFS.
Authority: 14 NYCRR Part 702 provides the authority for the Justice Center to request SSN for purposes of a SEL check.
Authorized Person Information: Work Email is required.
| Question | Answer |
|---|---|
| Form Name | Form JC CBC 3 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 19 |
| Avg. time to fill out | 4 min |
| Edition | Rev 4/22 |
| Where to send | Email or fax to the Justice Center |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | JC CBC 3, CBC 3, JC-CBC-3, CBC form, Request for Staff Exclusion List Check Form |
| Official source | JC CBC 3 (4/22), Justice Center |
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