Provider Resources
Authorization and Release for Protective Services Record Check
Form - BCF-PSRC 6/2005 (FOR OFFICIAL AGENCY USE ONLY)Use of Form
This form may be downloaded and used to request a check of child and adult protective services records in the Families and Children Tracking System (FACTS) to determine if an individual has a record of substantiated maltreatment of a child or adult. This form is for official agency use only. Any other use would be considered fraudulent.
Who May Use the Form
Only the following agencies or providers may request a check on an employee, volunteer or resident:
- Licensed child placing agencies (Online database available)
- Licensed group residential facilities (Online database available)
- Licensed child care centers (Online database available)
- Other family services agencies required by state law, licensing regulations, or DHHR policy or contract language to complete protective services background checks on potential/current employees or volunteers.
- Other states and agencies as required by the Adam Walsh Child Protection and Safety Act of 2006
Note: Those individuals seeking information about Nurse Aides, please go to the Nurse Aide Registry at www.wvdhhr.org/ohflac/na/
How to Complete the Form
- The requesting agency may download the on-line form and make copies as needed for employees, volunteers and household members.
- All employees, volunteers or household members should be given a copy of the form with an explanation of its use.
- The employee, volunteer or household member should complete the form by entering their full (first, middle and last) name, birth date, social security number and current home address, including the actual location and post office box, if the individual has a P.O. Box.
- If the employee/volunteer/household member has had other addresses within the past five years, all of them need to be listed.
- The employee/volunteer/household member should list maiden names, previous married names, aliases, nicknames or any other names known by.
- The next line should have the name and full address of the employing agency or provider who needs to receive the information, not the name of the person signing the release. The employing agency may want to enter this on forms before giving them to employees to make sure this address is correct. The form will be returned only to an agency address, not to individuals.
- The employee, volunteer or household member should check the box which shows their relationship to the agency that is requesting the information.
- The employee, volunteer or household member should read the certification. If the individual has any history of committing either child or adult abuse or neglect, it should be written in the space provided.
- The employee, volunteer or household member should read the authorization, which allows the Department to search its records and inform the employing agency or provider whether or not there is any record of substantiated maltreatment. The form should be signed and dated and returned to the employing agency/provider.
- As of July 1, 2005, the employing agency is to send the original copy of the completed form to the address below:
350 Capitol Street, Room 691
Charleston, WV 25301
Note: While checks have in the past been completed on a local level, the process has not been consistent across counties. The process has also created an additional burden on field staff whose time should be spent assisting vulnerable children and adults. The Bureau believes programs and families will be better served and the process more efficient, if it was performed centrally by staff members who have been assigned to this specific duty.
Rationale for Protective Services Checks
The desire of family-serving agencies to be more conscientious of the criminal and social backgrounds of their employees and providers has led to stricter screening processes and licensing regulations that require background checks of child and adult protective services records. The licensing regulations are as follows:
- WV Licensing Regulations for Child Placing Agencies , section 6.6.c for Employees states: "Each record for an employee shall include," 6.6.c.11. "A Completed "Statement of Child Abuse or Neglect History" form."
- Child Caring Regulations for Group Residential Facilities R3.11 states: "A residential facility shall not hire, or continue to employ, any person whose health, educational achievement, emotional or psychological makeup impairs his/her ability to properly protect the health and safety of the children or is such that is would endanger the physical or psychological well-being of the children." R1.7 also states: "The governing body of a residential facility shall be responsible for ensuring the facility's continual compliance and conformity with the terms of all leases, contracts, or other legal agreements to which the facility is a party.
- WV Licensing Regulations for Child Care Centers, section 8.4.d, A center shall ensure that each staff member and volunteer has a completed, signed, and dated Authorization and Release for Protective Services Record Check. The release shall be on file no later than the date of hire.
- WV Family Day Care Facility Regulations, sections 5.4.a: “The department shall conduct background checks on all operators, care givers, employees, volunteers eighteen years and over, and all adult household members and residents. Section 5.4.b states that the “operator shall not knowingly hire or continue to employ any staff person nor permit a volunteer or household member to be in contact with children in the home if any of these persons has been determined to have abused or neglected an adult or child.
- WV Family Day Care Home Registration Requirements, section 6.4 states that “a caregiver and each adult household member shall sign a consent to check Department records for child and adult abuse and neglect.
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