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The Central Registry Release Information form serves as a vital tool for individuals seeking information about their status in the Virginia Child Abuse and Neglect Central Registry. This form is essential for various purposes, including compliance with legal requirements under the Virginia Child Protective Law. It contains personal details that can determine whether an individual has been identified as an abuser or neglector in official investigations by Child Protective Services. To ensure accuracy, each applicant must meticulously complete the form, providing data such as full names, previous names, and vital statistics. Notably, this form must be notarized, reflecting its importance and the sensitive nature of the information it involves. A $10 search fee is required, underscoring the formal process surrounding these requests. Any incomplete or improperly filled form will be returned, emphasizing the necessity for thoroughness. Furthermore, the search results generated from this request are strictly non-transferable and can only be accessed by the requesting party, ensuring privacy and compliance with legal standards. Addressing the specifics of the form is crucial for achieving swift results.

Central Registry Release Information Example

VA Department of Social Services

Central Registry Release of Information Form

Office of Background Investigations – Search Unit

 

801 East Main Street, 6th Floor, Richmond, VA 23219-2901

Search Fee $10.00

 

INSTRUCTIONS

Purpose

The Virginia Child Abuse and Neglect Central Registry is mandated by the Virginia Child Protective Law and contains the names of individuals identified as an abuser or neglector in founded child abuse and/or neglect investigations conducted in the state of Virginia. The findings are made by Child Protective Services staff in local departments of social services and are maintained by the Virginia Department of Social Services. Legal mandates for the Virginia Department of Social Services to provide a Central Registry and a mechanism for conducting searches of the registry are found in § 63.2-1515 of the Code Virginia.

Read all instructions before completing the form: (Incomplete forms will be returned)

1.Answer all questions completely and accurately by printing clearly in black ink or typing your answers. Failure to complete or print clearly may delay or deny your request. Given the nature of the form and the actions to be taken when received, the Office of Background Investigations shall not accept forms that have been altered in any fashion. Forms that contain strike outs, correction tape or white-out will be returned.

2.If a middle name is an initial, indicate “initial only” otherwise, enter a full middle name given at birth.

3.For “other names used” list all previous names; nick names, all previous married names, legal name changes, changes due to adoption, etc. Circle appropriate title description on the form.

4.If the answer to any question is none, write “N/A“.

5.Sign the Central Registry Release of Information Form in the presence of an official Notary Public. Each

request form must be notarized. Only original signatures will be accepted. No copies of the form will be accepted.

6.A $10.00 fee is charged for each search. Payment must accompany search forms. Only money orders, company/business checks, or cashier checks will be accepted. (If multiple requests are mailed together, payment may be combined on in one money order, company/business check, or cashier’s check.

(ex. 4 requests at $10.00 each will total $40.00). A $50 fee will be charged for all returned checks.)

All money orders, company/business checks, or cashier checks should be made payable to: Virginia Department of Social Services.

Personal checks and cash will not be accepted.

7.For agencies and facilities that require several searches per year, an agency code will be assigned to expedite processing of the search requests.

8.If additional space is needed to complete the form (ie. providing information on addresses, spouses, and children) attach an 8x11 sheet sheet of paper along with your form to be mailed.

9.Search results are not transferable and are not considered official beyond the requesting agency or individual.

10.Mail your completed form and additional sheets (if used) to:

Virginia Department of Social Services

Office of Background Investigations - Search Unit 801 East Main Street, 6th Floor

Richmond, VA 23219-2901

032-02-0151-12-eng (08/15)

VA Department of Social Services

 

 

 

 

 

 

Central Registry Release of Information Form

Office of Background Investigations – Search Unit

 

 

 

 

 

 

 

 

 

 

 

 

801 East Main Street, 6th Floor, Richmond, VA 23219-2901

 

 

Search Fee $10.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Purpose of Search, Check one:

 

Adam Walsh Law

Adoptive Parent

Babysitter/Family Day Care

 

CASA

Children’s Residential Facility

 

Custody Evaluation

Day Care Center

Foster Parent

 

Institutional Employee

Other Employment

School Personnel

 

Volunteer

Other

 

MAIL SEARCH RESULTS TO: Agency, Individual or Authorized Agent Requesting Search

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

Payment/FIPS Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Use only if assigned by OBI-CRU)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name

 

 

 

 

Tel.#

 

 

Ext

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandatory if agency code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact E-Mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

has been assigned

 

 

PART I: DETAILS OF INDIVIDUAL WHOSE NAME MUST

BE SEARCHED

 

 

 

Last Name

 

 

 

First Name

 

 

 

 

 

Full Middle Name – (given at birth) - No initials

 

 

 

 

 

 

 

 

 

(if middle name is an initial, indicate "Initial Only")

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden Name (last name before marriage)

 

Sex

 

 

Date of Birth (MM/DD/YYYY)

 

Race

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver's License Number or ID #

 

 

Social Security Number

 

Other names used; nicknames, legal names (refer to instruction page)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Address (Include Street # and Apt #)

City

State

Zip

Applicant’s Prior Addresses

Include Street # and Apt #

 

 

 

City

 

State

 

Zip

Start Date (MM/YY)

End Date (MM/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status

Single

Married

Divorced

Widowed

Partner

 

 

 

 

 

 

If married, list current spouse. If previously married, list all previous spouses. If you have never been married, write ‘N/A’.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

 

Full Middle Name

Maiden Name

Race

Sex

 

 

Date of Birth

 

 

 

 

(given at birth)

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all of your children. If you have none, write ‘N/A’. Include all adult children, step and foster children not living with you.

Last Name

First Name

Full Middle Name

Relationship

Sex

 

Date of Birth

 

 

(given at birth)

 

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

032-02-0151-12-eng (08/15)

VA Department of Social ServicesCentral Registry Release of Information Form

Office of Background Investigations – Search Unit

 

801 East Main Street, 6th Floor, Richmond, VA 23219-2901

Search Fee $10.00

 

 

 

 

 

PART II: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION

I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge. Pursuant to Section 2.2-3806 of the Code of Virginia, I authorize the release of personal information regarding me which has been maintained by either the Virginia Department of Social Services or any local department of social services which is related to any disposition of founded child abuse/neglect in which I am identified as responsible for such abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this in his/her presence.

Signature of person whose name is being searched (Sign in presence of Notary)

Parent or Guardian signature required for minor children under the age of 18

PART III: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL

City/County of

Commonwealth/State of

Acknowledged before me this

 

day of

 

, year

 

 

 

 

 

 

 

 

 

 

 

Notary Public Signature1otary Number

My Commission Expires:

 

 

 

 

 

 

 

 

 

Notary Seal

PART IV: CENTRAL REGISTRY FINDINGS – COMPLETED BY CENTRAL REGISTRY STAFF ONLY

1.We are unable to determine at this time if the individual for whom a search has been requested is listed in the Central Registry. Please answer the following questions and return to the Central Registry Unit in order for us to make a determination:

Worker:Date:

2.Based on information provided by the Local Department of Social Services, we have determined that

is listed in the Child Abuse/Neglect Central Registry with a

founded disposition of child abuse/neglect. For more detailed information, contact the

Dept. of Social Services in reference to referral

 

phone#

Dept. of Social Services in reference to referral

 

phone#

3.As of this date, based on the information provided, the individual whose name was being searched is NOT identified in the Central Registry of Child Abuse/Neglect.

Signature of worker completing search:

 

Date:

 

OBI Staff Only

 

032-02-0151-12-eng (08/15)

Form Characteristics

Fact Name Description
Purpose of the Form The form is used to request information from the Virginia Child Abuse and Neglect Central Registry, which lists individuals identified as abusers or neglectors in founded investigations.
Legal Basis The operation of the Virginia Child Abuse and Neglect Central Registry is governed by the Virginia Child Protective Law, specifically under § 63.2-1515 of the Code of Virginia.
Fees A fee of $10.00 is required for each search. Payments can only be made via money orders, company checks, or cashier's checks; personal checks and cash are not accepted.
Notarization Requirement The form must be signed in the presence of an official Notary Public. Only original signatures are accepted, and alterations of any kind will result in the form being returned.

Guidelines on Utilizing Central Registry Release Information

Once you have received the Central Registry Release of Information form, follow these steps to ensure accurate and complete submission. After your form is filled out and submitted, it will undergo a review process by the Virginia Department of Social Services before you receive a response to your request.

  1. Carefully read all instructions provided on the form to ensure understanding.
  2. Print clearly in black ink or type your answers, ensuring that all questions are answered completely and accurately.
  3. If your middle name is an initial, specify "initial only." Otherwise, provide your full middle name given at birth.
  4. List all previous names, including nicknames and marriage names, in the “other names used” section. Make sure to circle the appropriate title description.
  5. If a question does not apply, write “N/A” in the space provided.
  6. Sign the form in front of a Notary Public. Remember, each request form must be notarized.
  7. Prepare payment of $10.00 in the form of a money order, company/business check, or cashier check; personal checks and cash are not accepted.
  8. If necessary, attach an 8x11 sheet of paper to provide additional information, such as addresses or names.
  9. Mail the completed form and any attachments to the designated address: Virginia Department of Social Services, Office of Background Investigations, 801 East Main Street, 6th Floor, Richmond, VA 23219-2901.

What You Should Know About This Form

What is the purpose of the Central Registry Release of Information Form?

The Central Registry Release of Information Form is utilized to conduct a search of the Virginia Child Abuse and Neglect Central Registry. This registry contains the names of individuals who have been identified as an abuser or neglector in founded investigations of child abuse or neglect. The findings are compiled by local Child Protective Services and stored by the Virginia Department of Social Services. Individuals and agencies seeking information about their status or a specific person's status within the registry need to complete and submit this form.

What information is required to complete the form?

When filling out the form, complete and accurate details are important. You must provide personal information such as full name, date of birth, social security number, and any previous names used. Additionally, you need to list your current address and past addresses, marital status, and details about your children if applicable. The instructions emphasize clarity and completeness—illegible or incomplete forms will be returned. It is also crucial to notarize the form and ensure all payments are made with acceptable methods.

How much does it cost to conduct a search, and what payment methods are accepted?

A fee of $10.00 is required for each search. Payments must accompany the completed form. Acceptable payment methods include money orders, company/business checks, and cashier's checks made out to the Virginia Department of Social Services. Personal checks and cash are not accepted to ensure secure and traceable transactions. If you are submitting multiple requests, you can combine the total amount into one payment.

What happens after I submit the form?

Once you submit your completed form along with payment to the Office of Background Investigations, the staff will process your request. You will receive results indicating whether or not you or the individual searched is listed in the Central Registry. It is important to note that the search results are not transferable and should be used solely for the intended agency or individual. If there are any issues, such as an incomplete submission, your form may be returned for correction, delaying the process.

Common mistakes

Filling out the Central Registry Release Information form requires attention to detail. One common mistake people make is leaving questions unanswered or providing incomplete information. The instructions clearly state that all questions must be answered completely and accurately. If the form is incomplete, it will be returned, leading to delays and potential issues in processing the request.

Another frequent error occurs with the documentation of names. Individuals often fail to provide all required names, including middle names, previous married names, and any legal name changes. It is crucial to list every previous name accurately as instructed, as failure to do so can cause complications in the search process.

People sometimes overlook the requirement for notarization. The form must be signed in the presence of a Notary Public, and only original signatures will be accepted. Submitting a form with a copy of the signature instead of an original will lead to its rejection. This step is essential for ensuring the authenticity of the request.

A fourth mistake arises from payment misunderstandings. Applicants often do not include the correct type of payment or fail to attach a money order, company check, or cashier’s check. Personal checks and cash are not accepted, so missing this detail can delay the processing time or result in the request not being fulfilled.

Additionally, neglecting to provide additional sheets when necessary is a common error. The form provides limited space for information about previous addresses, spouses, and children. If more room is needed, applicants should attach an 8x11 sheet of paper. Failing to do this may cause incomplete information to be submitted, which can lead to further complications.

Finally, not reading or following the instructions can result in errors. The form includes specific guidelines about formatting and what to include or exclude. By skimming through the details or making assumptions, applicants risk returning a form that cannot be processed efficiently. Careful attention to the instructions can help avoid these pitfalls.

Documents used along the form

The Central Registry Release of Information form plays a critical role in Virginia's child protection efforts. Alongside this form, several other documents may be required or helpful in various contexts. Here is a list of related forms and documents that you might encounter when engaging with the Virginia Department of Social Services or similar entities.

  • Background Check Authorization Form: This document allows individuals to grant permission for a background check to be conducted. It often includes personal details such as names, addresses, and Social Security numbers to verify identity and assess any criminal history.
  • Notary Acknowledgment Form: Used to certify that the signature on the Central Registry Release of Information form was made in the presence of a notary public. This verifies the authenticity of the signature and the identity of the signer.
  • Child Protective Services (CPS) Case Information Form: This form gathers detailed information on cases where child abuse or neglect has been reported. It includes names, addresses, and other relevant details about the involved parties, conducting agency, and the nature of the report.
  • Court Order for Information Release: In certain cases, a court may issue an order requesting specific information from the Central Registry. This document outlines the legal basis for accessing private records and includes details on what information is to be disclosed.
  • Employment Reference Release Form: If an individual is applying for a job that involves working with children, this form allows potential employers to verify past employment and any relevant background regarding child care or interaction.
  • Temporary Custody Agreement: This document details arrangements made for the temporary custody of a child, including the parties involved, duration, and conditions. Such agreements can play a role in legal situations where child welfare is of concern.
  • Request for Reconsideration Form: If someone disagrees with findings from the Central Registry, they can file this request to challenge the decision. This form outlines the reasons for the appeal and may request a review of the information held in the registry.
  • Personal Identification Forms: These forms help establish the identity of the individual requesting information from the Central Registry. They may require copies of government-issued identification such as driver’s licenses or passports.

Understanding these related forms and documents can streamline the process of navigating child protection and background checks. Always ensure that you provide accurate and complete information to avoid delays or complications in your requests.

Similar forms

The Central Registry Release Information form has similarities with the following documents:

  • Background Check Request Form: Like the Central Registry form, this document is used to request a background check on an individual, often required for employment or volunteering. Both forms ensure that the applicant is properly identified and that the information is accurate.
  • Child Protective Services (CPS) Report Request: This request form is utilized to obtain reports related to child abuse and neglect investigations. Similar to the Central Registry form, it requires detailed personal information to process the request.
  • Employment Verification Form: Employers often use this form to verify an applicant’s past employment history. It requests permission and necessary identifying information, much like the details requested on the Central Registry form.
  • Release of Information Consent Form: This document allows an individual to grant permission for their personal information to be shared with a third party. The Central Registry form also requires consent from the individual whose information is being sought.
  • Adoption Background Check Form: This form is similar in purpose, used during the adoption process to ensure potential parents have no history of child abuse or neglect. Both documents involve a detailed search of personal histories.
  • Notarized Consent Form: Used in various legal situations, this form requires a signature witnessed by a notary public. The Central Registry form also mandates notarization to validate the request.

Dos and Don'ts

When filling out the Central Registry Release Information form, consider these important guidelines to ensure your application is processed smoothly:

  • Complete all sections of the form thoroughly. Take your time to answer every question accurately.
  • Use clear, black ink or type your responses. This allows for better legibility and helps prevent delays.
  • If you have a middle name that is only an initial, make sure to indicate it as “initial only.” Otherwise, provide your full middle name.
  • List all previous names you’ve used, including nicknames, former married names, and legal name changes.
  • Sign the form in front of a Notary Public. Ensure that your signature is original; copies are not accepted.
  • Prepare your payment correctly. Only send money orders, company checks, or cashier checks, as personal checks and cash are not accepted.
  • If another sheet is required for additional information, label it clearly and attach it securely.
  • Double-check that the mailing address on the form is complete and accurate before sending it in.

Avoid these common mistakes that could lead to delays or rejection:

  • Do not leave any questions unanswered. Incomplete forms will be returned, causing setbacks.
  • Never alter the form. Using correction tape or white-out is strictly prohibited. If mistakes are made, start with a new form.
  • Avoid sending cash or personal checks with your submission. This may lead to automatic rejection.
  • Do not send in photocopies of the form. Every submission must have an original signature.
  • Refrain from listing “N/A” in places where specific information is required.
  • Do not assume that search results can be transferred to others. They are typically only valid for the requesting individual or agency.
  • Avoid using non-standard paper sizes if you need extra space. Stick to the specified 8x11 sheet size for additional details.
  • Do not mail your completed form without verifying that all information is accurate and complete.

Following these guidelines will help ensure the timely processing of your request. Be diligent; taking these extra steps can save you time and effort in the long run.

Misconceptions

Misconception 1: The Central Registry Release Information form is only for people directly involved in child care.

This form can be used by various individuals and organizations, including potential adoptive parents, foster parents, and volunteers in child-related activities. It’s essential for anyone who may need to demonstrate their background regarding child abuse or neglect allegations.

Misconception 2: You do not need to provide a complete history of other names.

It is crucial to list all previous names, including nicknames and married names. Incomplete name history may lead to delays or complications in the search process.

Misconception 3: You can submit a copy of the completed form.

Only original forms with original signatures are accepted. Copies or altered forms will be rejected and returned.

Misconception 4: Personal checks are acceptable for payment.

Only money orders, cashier checks, or company checks are permitted. Personal checks and cash will not be accepted, ensuring secure payment methods for all search requests.

Misconception 5: You can mail the form without notarizing it.

Each form must be signed in the presence of a Notary Public. Notarization verifies that the information provided is accurate and legally binding.

Misconception 6: The search results are automatically sent to the requester.

Search results must be mailed directly to the agency, individual, or authorized agent as specified on the form. They are not transferred automatically or shared outside the requesting entity.

Misconception 7: You only need to include current addresses.

Prior addresses must also be listed. Providing a complete history helps in accurately conducting the search.

Misconception 8: The search fee is a one-time charge without any conditions.

A $10 fee is required for each search request. This means if multiple requests are needed, the fees should be combined in one payment.

Misconception 9: You cannot attach additional sheets for further information.

If more space is necessary to complete the form, you can attach an additional 8x11 sheet of paper with the required information. This helps ensure all details are captured accurately.

Misconception 10: Submitting an incomplete form will not affect the search.

Submitting an incomplete or improperly filled form will lead to delays or outright rejection. It is crucial to follow all instructions and complete every section to avoid issues.

Key takeaways

Filling out the Central Registry Release Information form is essential for ensuring accurate and thorough background checks related to child abuse and neglect. Consider the following key points:

  • Complete Accuracy: Answer all questions completely and accurately. Use black ink or type your responses. Incomplete forms will be returned, causing delays.
  • No Alterations: Do not alter the form in any way. Forms with corrections, strike outs, or white-out will not be accepted and will be sent back.
  • Notarization Required: Each form must be signed in front of a Notary Public. Original signatures are necessary; photocopies will not be accepted.
  • Payment Methods: A $10.00 search fee is required. Only money orders, cashier checks, or company/business checks will be accepted. No personal checks or cash.
  • Confidentiality of Results: Search results from the form are not transferable. They are specific to the requesting agency or individual.
  • Proper Mailing: Mail your completed form to the Virginia Department of Social Services. Ensure all instructions are followed to prevent returns.

Following these steps ensures a smooth process and helps maintain the integrity of the background search procedure. It is important to be thorough and careful when handling this sensitive information.