Form Jc Cbc 3 – Fill Out and Use This PDF

THIS FORM IS ONLY TO BE USED WHEN AN APPLICANT HAS NOT BEEN ISSUED A SOCIAL SECURITY NUMBER OR ALIEN REGISTRATION NUMBER. All other Staff Exclusion List checks should be done online. Please direct any questions to cbc@JusticeCenter.ny.gov

The Justice Center maintains a Vulnerable Persons Central Register (VPCR) that includes a Staff Exclusion List (SEL) containing the names of individuals who have committed serious acts of abuse and are deemed ineligible to work in a position involving regular and substantial contact with a service recipient. Providers must request the Justice Center to conduct a check of the SEL before determining whether to hire or otherwise allow any person to have regular and substantial contact with a service recipient.

Instructions:

1.The provider’s Authorized Person must complete this form and fax it to the Justice Center’s Criminal Background Check (CBC) unit for an applicant under serious consideration to be hired or otherwise permitted to have regular and substantial contact with a service recipient.

This form should not be used as a screening tool for all applicants.

2.The Justice Center’s CBC unit will send the Authorized Person an email indicating the results of the SEL check.

3.If the Applicant is on the SEL, he or she may not be hired in a position involving regular and substantial contact with a service recipient in a facility or provider agency defined in

Social Services Law §488(4) or by other providers of services in programs licensed or certified by the Office of Mental Health, Office for People With Developmental Disabilities, Office of Alcohol and Substance Abuse Services, Office of Children and Family Services, Department of Health and State Education Department.

4.If the Applicant is on the SEL, certain other providers have discretion whether to hire the individual as provided in Social Services Law §495(3).

5.If the Applicant is not on the SEL, a criminal background check through the Justice Center, if required, and an inquiry of the Statewide Central Register of Child Abuse and Maltreatment

through the Office of Children and Family Services, if required, must be conducted.

Part 1. Applicant Information

	Oversight Agency:	OMH OPWDD DOH SED OASAS OCFS
	(Please check one)

Part 2. Authorized Person Information

Name:

Work Email Required

Facility/Provider

Name:

Phone:

JC CBC 3 (7/14) Made Fill-able by DM