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The Louisiana Central Registry Disclosure Form plays a crucial role in safeguarding children by ensuring that individuals working in child care and juvenile detention facilities are properly vetted. This form must be filled out by every owner, operator, administrator, current or prospective employee, and volunteer associated with licensed facilities under the Louisiana Department of Children and Family Services (DCFS). It collects essential personal information, including the individual’s name, date of birth, Social Security number, and current and previous addresses. The form also requires a declaration regarding any past findings of child abuse or neglect. If someone knowingly provides false information, they may face serious consequences, including fines or imprisonment. Maintaining this form is not just a regulatory requirement; it is a commitment to the safety and well-being of the children in these facilities. The licensed facility must keep this documentation in accordance with state licensing standards, reinforcing the importance of transparency and accountability in child care settings.
Louisiana Central Registry Example
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 |
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currently recorded as a perpetrator on the State Central Registry for what the |
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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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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 |
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Documents used along the form
The Louisiana Central Registry form is an essential document for individuals involved in child care or juvenile detention facilities. Along with this form, several other documents are commonly required to ensure compliance with state regulations. Here’s a brief overview of these additional forms and documents.
- Background Check Authorization Form: This form allows the state to conduct a background check on individuals applying for positions within child care or juvenile detention facilities. It collects personal information needed to verify criminal history and ensure the safety of children.
- New York Bill of Sale: Similar to other forms, the legalpdf.org provides resources for individuals to create a Bill of Sale, ensuring that ownership transfers are documented properly within the state of New York.
- Child Abuse and Neglect Training Certificate: This certificate verifies that an individual has completed training on recognizing and reporting child abuse and neglect. It is often required for all staff members to ensure they are equipped to handle such situations appropriately.
- Employment Application: This standard application form collects essential information about a candidate's work history, education, and qualifications. It helps the facility assess the suitability of applicants for positions within the organization.
- Health and Immunization Records: These records provide proof of an individual’s health status and immunizations. Facilities often require this documentation to ensure that staff and volunteers are healthy and can safely work with children.
These documents work together to create a safe environment for children in care. Completing all required forms accurately is crucial for compliance with Louisiana regulations.
Key takeaways
Filling out the Louisiana Central Registry form is a crucial step for anyone involved in child care or juvenile detention facilities. Here are some key takeaways to keep in mind:
- Accuracy is Essential: Ensure that all information provided is truthful and complete. Falsifying any details can lead to serious consequences, including fines or imprisonment.
- Who Needs to Complete the Form: This form must be filled out by every owner, operator, administrator, employee, or volunteer associated with a licensed facility. Everyone involved plays a vital role in maintaining safety standards.
- Understand the Consequences: If your name appears on the State Central Registry as a perpetrator of child abuse or neglect, the Licensing Section may act without your consent. This could impact your employment and legal standing.
- Keep Records Updated: The licensed facility must maintain this form according to current licensing standards. Regularly check that all information remains current to avoid compliance issues.
Being diligent in completing and using the Louisiana Central Registry form can protect not only you but also the children in your care. Act promptly and responsibly.