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*
Employer Email Address*
example@example.com
Requestor’s Last Name*
Requestor’s First Name*
Facility:*

Hourly Services
Placemarker*
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
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:*

MaleFemale
Race*
DOB*

MonthDayYear
Date
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.*

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Date*

MonthDayYear
Date
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ALABAMA DEPARTMENT OF HUMAN RESOURCES CLEARANCE FORM

Employer Section

The Following Section to be completed by Applicant