In Louisiana, the safety and welfare of children in child care settings are paramount, which is why the State Central Registry Disclosure Form plays a critical role. This form is a requirement for every individual who is an owner, operator, administrator, or a current or prospective employee or volunteer at child care and juvenile detention facilities licensed by the Louisiana Department of Children and Family Services. The purpose of this form is multifaceted: it serves as a vetting tool to ensure the safety of children by requiring disclosures regarding one's criminal background, specifically concerning any history of child abuse or neglect. Individuals must declare whether their name is recorded as a perpetrator on the State Central Registry with a justified (valid) finding of child abuse or neglect. Falsification of information on this form is treated with utmost seriousness, with perpetrators facing misdemeanor charges, including fines and possible incarceration. Additionally, this document must be maintained by the facility's owner/operator in alignment with current licensing standards. Through these measures, the State Central Registry Disclosure Form not only acts as a safeguard for children but also as a mechanism to maintain transparency and accountability within Louisiana's child care system.
| Question | Answer |
|---|---|
| Form Name | Louisiana Central Registry Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | scr form louisiana, louisiana disclosure, louisiana registry form, la central registry |
Rev. 01/13
06/11 Issue Obsolete
STATE OF LOUISIANA
DEPARTMENT OF CHILDREN AND FAMILY SERVICES STATE CENTRAL REGISTRY DISCLOSURE FORM
This form must be completed by each individual owner, operator, administrator, current or prospective employee or volunteer of a child care facility or juvenile detention facility licensed by the Louisiana Department of Children and Family Services for themselves. Any owner, operator, administrator, current or prospective employee, or volunteer of a child care facility or juvenile detention facility licensed by the department who knowingly falsifies the information on the State Central Registry Disclosure Form shall be guilty of a misdemeanor offense and shall be fined not more than five hundred dollars, or imprisoned for not more than six months, or both. R.S. 46:1414.1.C or R.S. 15:1110.2(C).
This form shall be maintained by the owner/operator of the licensed facility in accordance with current licensing standards as mandated by R.S. 46:1414.1.B or R.S. 15:1110.2(B).
Name of Licensed Facility (Print or Type)
Physical Address of Licensed Facility |
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License # |
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Name of Individual/Applicant (Print or Type) |
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Date of Birth |
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Social Security # |
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Maiden, Previous or Any Other Name Used |
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Race |
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Sex |
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Current Street Address |
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City and State |
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Zip Code |
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Most Recent Previous Address |
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City and State |
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Zip Code |
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Current Home Phone # |
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Current Cell Phone # |
Work Phone # |
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My name |
is |
is not |
currently recorded as a perpetrator on the State Central Registry for what the |
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(check one) |
Department of Children and Family Services (DCFS) has determined to be a justified |
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(valid) finding of child abuse or neglect. |
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I |
have |
have not |
been determined to have a justified (valid) finding of abuse or neglect since the Risk |
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Evaluation Panel finding. |
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If the DCFS Licensing Section has reasonable suspicion or is provided with facts or information that your name is on the State Central Registry as a perpetrator with a valid/justified finding of abuse and/or neglect, the Licensing Section may request a clearance of the SCR without your permission. If your name does in fact appear on the SCR as described above, the department will notify both your employer (the facility named above) and the appropriate District Attorney’s office of your failure to comply with R.S. 46:1414.1 or R.S. 15:1110.2.
The information given is true and complete to the best of my knowledge.
Signature |
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Date |
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Signature of Licensed Facility Representative |
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Date |