Louisiana Central Registry Form PDF Details

Are you looking for information on the Louisiana Central Registry Form, also known as a background check form? If so, you’re in the right spot. In this blog post, we'll provide an overview of what the Louisiana Central Registry Form is and why it's important to complete. We'll also look at which roles are required to submit them and explore how exactly one should go about filing their background check. By understanding the registration process and its requirements, you can apply for jobs with confidence that you will pass your employer's screening. So stick around to learn more about submitting a successful application!

QuestionAnswer
Form NameLouisiana Central Registry Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesscr form louisiana, louisiana disclosure, louisiana registry form, la central registry

Form Preview Example

SCR-1 LIC

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

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual/Applicant (Print or Type)

 

 

 

 

 

Date of Birth

 

 

 

Social Security #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden, Previous or Any Other Name Used

 

 

 

 

 

Race

 

 

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Street Address

 

 

 

 

 

 

 

City and State

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Most Recent Previous Address

 

 

 

 

 

 

City and State

 

 

 

 

 

Zip Code

(

)

-

 

 

 

(

)

-

 

 

 

 

 

 

(

)

-

 

 

Current Home Phone #

 

 

 

Current Cell Phone #

Work Phone #

 

 

 

 

My name

is

is not

currently recorded as a perpetrator on the State Central Registry for what the

 

 

(check one)

Department of Children and Family Services (DCFS) has determined to be a justified

 

 

 

 

(valid) finding of child abuse or neglect.

 

 

 

 

 

 

I

have

have not

been determined to have a justified (valid) finding of abuse or neglect since the Risk

 

 

 

 

Evaluation Panel finding.

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Date

 

 

 

Signature of Licensed Facility Representative

 

Date