Evangeline Parish Schools - DCFS CANS Form

STATE OF LOUISIANA DEPARTMENT OF CHILDREN AND FAMILY SERVICES CHILD ABUSE AND NEGLECT REQUEST AND CONSENT FORM B
This form must be completed by any person who is requesting a Child Abuse and Neglect Clearance, and signed by the applicant. This form must be signed by the requestor, who will receive the results of the child abuse and neglect clearance. Completing the optional identifying information fields on the form will assist in conducting an accurate search.

This consent form shall be used for Licensed Out of State Child Care Facilities; Louisiana DCFS Licensed Facilities; Louisiana Department of Health Licensed Therapeutic Group Homes; Out of State Licensed Residential Facilities that house foster children or meet the federal definition of a child care institution; In State Licensed Office of Juvenile Justice Detention Center employees; In State School Administrators, Teachers, or Other School Employees; and Owners, Operators, or participants in the governance of an In State DCFS Licensed residential facility.

Note: Licensed Early Learning Centers located on school campuses must utilize the background clearance process through LDOE
Applicant’s Information:
Name*

First NameMiddle NameLast Name
Aliases, Maiden Name, Previous Married Name(s)
Date of Birth*

MonthDayYear
Date
Race*

WhiteBlack/African-AmericanAmerican Indian / Alaskan NativeAsianOtherNative Hawaiian / other Pacifice
Place of Birth (city) *
Place of Birth (state)*
Social Security #*
Male or Female*
Home Phone # (one main contact number is mandatory)*
Current Physical Address*

Current Physical Address

Street Address Line 2

CityState

Zip
Cell Phone*
Work Phone #*
Alternate Phone #
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
Email Address*
example@example.com
Identification Type*

State Issued Driving LicenseState Issued Identification
Identification (ID)*
State Issued By*
ID Expiration Date*

MonthDayYear
Date
Marital Status*
Spouse Name (if married)
Spouse (DOB) (if married)

MonthDayYear
Date
Previous Spouse1 (name)
Previous Spouse 1(DOB)

MonthDayYear
Date
Previous Spouse2 (name)
Previous Spouse2 (DOB)

MonthDayYear
Date
*List previous addresses for the past 5 years:
Address (1)

Physical Address

Street Address Line 2

CityState

Zip
Address (2)

Physical Address

Street Address Line 2

CityState

Zip
Address (3)

Physical Address

Street Address Line 2

CityState

Zip
Address (4)

Physical Address

Street Address Line 2

CityState

Zip
Address (5)

Physical Address

Street Address Line 2

CityState

Zip
List children that the applicant has been responsible for: (*This information will only be used to confirm the accuracy of the applicant’s agency history.)
Child 1: First Name
Child 1: Last Name
Child 1: Date of Birth

MonthDayYear
Date
Child 1: Gender
Child 2: First Name
Child 2: Last Name
Child 2: Date of Birth

MonthDayYear
Date
Child 2: Gender
Child 3: First Name
Child 3: Last Name
Child 3: Date of Birth

MonthDayYear
Date
Child 3: Gender
Child 4: First Name
Child 4: Last Name
Child 4: Date of Birth

MonthDayYear
Date
Child 4: Gender
Child 5: First Name
Child 5: Last Name
Child 5: Date of Birth

MonthDayYear
Date
Child 5: Gender
Child 6: First Name
Child 6: Last Name
Child 6: Date of Birth

MonthDayYear
Date
Child 6: Gender
Child 7: First Name
Child 7: Last Name
Child 7: Date of Birth

MonthDayYear
Date
Child 7: Gender
The information given is true and complete to the best of my knowledge. I understand that in signing this form I give permission for DCFS to conduct a clearance of the State Central Registry which contains information with regards to reports of certain valid/substantiated cases of child abuse and neglect, and release the results to the requestor noted above and licensing agency. Furthermore, this consent shall terminate a year from the date of my signature below. I also understand that I may be contacted by DCFS for additional information needed to finalize the clearance. I understand that the information I provide about myself shall be used solely for the purpose of conducting the State Central Registry check. I consent for DCFS to conduct a clearance of the state central registry and release all valid substantiated information to the requestor below for a determination to be made.
Signature of Applicant*

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Date

MonthDayYear
Date
I acknowledge that any information received from the Department of Children and Family Services regarding the individual’s inclusion in the State Central Registry is confidential and that this information cannot be shared with anyone unless otherwise allowed by State or Federal Laws/Regulations. All applicable federal and state laws and regulations shall apply including but not limited to Louisiana Revised Statute 46:56, which includes criminal penalties for the sharing of confidential information. I hereby certify that I am requesting a check of the State Central Registry, with the written consent of the individual. I understand that the State Central Registry clearance results for school employees, along with owners, operators and participants in the governance of an In-State DCFS Licensed residential facility only include investigations that began on or after 8/1/18.
Printed Name of Requestor (EPSB HR Only)
Signature of Requestor (EPSB HR Only)

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Date

MonthDayYear
Date
If this clearance is being submitted for employment purposes, by a Licensed Out of State Child Care Facility, Louisiana DCFS Licensed Facility, Louisiana DCFS Licensed Therapeutic Group Homes, Out of State Licensed Residential Facilities that house foster children or meet the federal definition of a child care institution and In State Licensed Office of Juvenile Justice Detention Center employees the employee's state issued driving license or state issued identification, along with a $25.00 payment for the clearance must be submitted, in order for the clearance to be processed. For other clearance types a $25.00 payment will not be charged, however the employee’s state issued driving license or state issued identification, must be submitted.

CPS CANS Form-B Rev. 8/25
Should be Empty:

STATE OF LOUISIANA DEPARTMENT OF CHILDREN AND FAMILY SERVICES CHILD ABUSE AND NEGLECT REQUEST AND CONSENT FORM B

Applicant’s Information: