Texas Dept. of Family
and Protective Services / REQUEST FOR CHILD ABUSE/NEGLECT
CENTRAL REGISTRY / Form 2970
May 2013

As required by the Texas Family Code 261.002, DFPS maintains a central registry of reported cases of child abuse and neglect. The DFPS Central Registry consists only of information gathered during Child Protective Services (CPS), Child Care Licensing (CCL), and Adult Protective Services (APS) facility investigations of child abuse and neglect in cases which were given a disposition of "reason to believe" for CPS and CCL cases or “confirmed and validated” for APS cases, and the person had a role of designated perpetrator or sustained perpetrator (Please Note: Cases involving adult victims are not included in the DFPS Central Registry).

In addition, the person will not clear the Central Registry check if the person is involved as an alleged perpetrator in an open child abuse or neglect investigation being conducted by DFPS. A new Central Registry check may be requested at the conclusion of the investigation to determine if the person has been listed as a designated perpetrator on the Central Registry of Child Abuse and Neglect.

A person may request a Central Registry check on him or herself by completing, having notarized and submitting this form to:

CBCU Non-Licensing Unit, M/C 121-7

PO Box 149030, Austin, TX 78714-9030

(800) 645-7549

Requestor/Subject of the Background Check Section:

The information in this section must be provided by the requestor/subject of the background check in order for the check to be completed. Missing information may result in a delay of your request being processed.

First Name / Middle Name / Last Name
Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last (continue on back as needed)
Current Residence Street Address / City / County / State / Zip Code
Residence Telephone No. (A/C) / Date of Birth / Gender :
Male - Female / SSN
Race (check all applicable)
Am Indian/AK Native Nat Hawaii/Pacific
Asian White
Black Unable to Determine / Ethnicity (check one, only)
Hispanic
Not Hispanic
Unable to Determine
List any other additional addresses or cities in Texas that you have resided (continue on back as needed)
Please include an email address if you would like the results of the Central Registry check sent to you via email. If this section of the form is left blank the results will be mailed to the residence address listed above.
Purpose of Central Registry Request:
Individual currently living in Texas seeking Central Registry clearance for an adoption or social study.
Individual currently living outside of Texas seeking Central Registry clearance from Texas for an adoption or a social study.
Individual seeking to become a volunteer, employee or board member of an organization that is authorized to have employees, volunteers and board members to obtain checks through DFPS. Please note: A DPS criminal history check is also conducted for authorized organizations such as Make-A-Wish Foundation of America, I Have A Dream/Houston, and Big Brothers/Big Sisters of America.
Specify organization:______
Other: Please specify the reason a Central Registry check is being requested.
______

Designee Section:

If you would like the results of the Central Registry check sent to someone other than yourself please complete the designee section below. Please note: Only cleared results will be sent to the designee listed below. As the subject of the request, you have the right to review and follow up with DFPS regarding the results of this check. If Central Registry history is found that identifies you as a person who has been found to have abused or neglected a child, DFPS will only send the results directly to you via mail or e-mail; your designee will not receive any results.

If the section below is left blank, DFPS will assume that you would like the results of the check sent only to you.

SEND RESULTS OF REQUESTED CHECKS TO:
Name of Designee:
Please check below to indicate Agency/Entity the Designee Represents:
Mailing Address of Designee (City, State, Zip):
Email Address:

Signature Section:

This form must be signed by the requestor/subject of the background check and not the designee.

By signing this form you are giving DFPS permission to complete a background check using the information that you provided above.

Signature of Requester ______Date of Request ______

SUBSCRIBED AND SWORN TO before me this _____ day of ______, ______.

[Notary stamp or seal]

______

Notary Public