ALABAMA DEPARTMENT OF HUMAN RESOURCES ALABAMA ELDER AND ADULT IN NEED OF PROTECTIVE SERVICES ABUSE REGISTRY CLEARANCE

ALABAMA DEPARTMENT OF HUMAN RESOURCES CLEARANCE FORM

This document is only for DSPs who will be working for Sunbridge's IDD/CWP program. Your completed fields below will be used for the clearance document that is required by the State of Alabama. Once you complete your portion below, a Sunbridge representative will review your entries and submit the required document.
Employer Section
Employer - Agency/Organization Name
Employer - Street Address
City
State
Zip Code
Employer - Phone Number
Format: (000) 000-0000.
Employer Email Address
example@example.com
Requestor’s Last Name
Requestor’s First Name
Facility:
Placemarker
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Description (2nd Line)
The Following Section to be completed by Applicant
Last Name
First Name
Middle (If you have a Middle Name, it is required for you to enter)
If you do not have a formal middle name, please type "None" or "N/A" in this field
Sex:
Race
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 digits of Social Security Number
Current Mailing Street Address
City
State
Zip Code
I authorize the Alabama Department of Human Resources (Department) to release information it maintains regarding any Alabama Adult Abuse Neglect and/or Exploitation investigation(s), Department of Mental Health investigation(s), Department of Public Health investigation(s), criminal convictions related to certain convictions and/or Protection from Abuse Orders about me to the above-named person/agency/organization. I hereby waive any right to any review or hearing to which I may otherwise be entitled. I further release the Department, its officers, and employees from any and all claims arising out of or in any way connected to the release or dissemination of any information concerning me. I understand information being reviewed may have been generated by agencies other than DHR. I understand the purpose of the review is to assist the Department in preventing Abuse, Neglect and/or Exploitation of vulnerable adults.
By signing below, I authorize Sunbridge Home Health Care to complete and submit this form on my behalf, including applying my signature where required. I understand that this authorization is provided voluntarily. I acknowledge that Sunbridge Home Health Care will provide me with a copy of the completed form once it has been finalized and submitted.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ALABAMA DEPARTMENT OF HUMAN RESOURCES CLEARANCE FORM

Employer Section

The Following Section to be completed by Applicant