STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
Division of State Police
Criminal Justice Business Applications Unit
Criminal History Record Information Requisition Form
Connecticut General Statute (CGS) section 10-221drequires public and nonpublic schools to obtain fingerprint-based state and national criminal history record information (CHRI) on applicants and workers.CGS 10-221d also allows regional education service centers (RESCs)to serve as pass-through entities for fingerprint submission and receipt or dissemination of CHRI on behalf of a requesting school.
As a pass-through entity, RESCs are required to validate each request for CHRI. This form shall be used to ensure statewide compliance and must be maintained by the requesting school and RESC for at least one (1) year from the date of the request. This form must be submitted to all RESCs before fingerprints can be taken or CHRI can be released to a requesting school effective October 1, 2017. RESCs are prohibited from submitting fingerprints or disseminating CHRI to requesting schools that have not obtained approval from the Connecticut State Police.In addition to this form, requesting schools must provide the RESCs with the National Child Protection Act/Volunteers for Children Act (NCPA/VCA) or Volunteer and Employee Criminal History Services (VECHS) Waiver and Consent Form when fingerprinting applicants under the NCPA/VCA.
Requesting schools must ensure that1.)It has been approved by the Connecticut State Police to receive CHRI;2.) It has an application on file for eachrequest and will maintain the application for at least one (1) year from the date of the request;and3.) The applicant meets the state or federal statutory requirement to be fingerprinted. Refer to the Approved State or Federal Statutory Authority Form (page 2).
A RESC may require additional forms or information to process a request.
Check the appropriate box and fill in the appropriate information.
Type of Request
Request for Applicant Fingerprinting / Request for CHRIRequesting School Information
District or Nonpublic School NameSchool Address / City/Town / Zip Code
Telephone # / Email Address
School Representative Name / Representative Title
Signature / Date
Applicant Information
Position Applying ForName / Date of Birth
Telephone # / Email Address
Approved State or Federal Statutory Authority
The state or federal statutes listed below have been approved for submission and dissemination by the Federal Bureau of Investigation and include the applicant types from Public Act 17-68. Select the applicant type based on the school type.
Statute / LOCAL OR REGIONAL BOARD OF EDUCATION APPLICANT TYPES / Select 1CGS 10-212 / The applicant will be appointed by or under contract with the school as a school nurse or nurse practitioner.This cannot be a nursing student.
CGS 10-221d / The applicant has been hired by the school and has 30 days to get fingerprinted.The applicant cannot be hired by the city/town to work in the school.
CGS 10-221d / The applicant will be placed within the school under a public assistance employment program.
CGS 10-221d / The applicant is in a nonpaid, noncertified position completing preparation requirements for the issuance of an educator certificate and will perform a service involving direct student contactwithin 30 days. This cannot be a nursing student.
CGS 10-221d / The applicant has been hired by the schoolas a substitute teacher. The applicant is cannot be a contracted worker from a private company.
AWA* / The applicant has applied for apaid position with or around children in an elementary or secondary school only. This includes a paid intern, paid nursing student,or contracted worker.
AWA Volunteer / The applicant has applied for an unpaid position with or around children in an elementary or secondary school only. This includes a volunteer or unpaid intern.
NCPA/VCA / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled in a paid position. This includes a contractor or other non-CGS paid position providing such services.
NCPA/VCA Volunteer / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled as a volunteer, unpaid intern, or other non-CGS unpaid position providing such services.
Statute / CT TECH HIGH SCHOOL, CHARTER SCHOOL, MAGNET SCHOOL APPLICANT TYPES / Select 1
AWA / The applicant has applied for a paid position with or around children in an elementary or secondary school only. This includes a paid intern, paid nursing student,or contracted worker.
AWA Volunteer / The applicant has applied for an unpaid position with or around children in an elementary or secondary school only. This includes a volunteer or unpaid intern.
NCPA/VCA / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled in a paid position. This includes a contractor or other paid position providing such services.
NCPA/VCA Volunteer / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled as a volunteer, unpaid intern, or other unpaid position providing such services.
Statute / ALL OTHER SCHOOL APPLICANT TYPES / Select 1
NCPA/VCA / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled in a paid position. This includes a contractor or other paid position providing such services.
NCPA/VCA Volunteer / The applicant will provide treatment, education, training, instruction, supervision, or recreation to children, the elderly, or the disabled as a volunteer, unpaid intern, or other unpaid position providing such services.
*Adam Walsh Act
Fingerprints submitted under CGS 10-212 or 10-221d require the state fee only.
Fingerprints submitted under AWA or NCPA/VCA requirestate and federal fees.
1111 Country Club Road Middletown, CT 06457
Phone (860) 685-8020
Connecticut State Police CHRI Requisition Form (9/2017) Page 1 of 2