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The Louisiana Central Registry Disclosure Form is a crucial document for anyone involved in the operation of child care or juvenile detention facilities within the state. It serves as a safeguard to ensure that individuals who work with children do not have a history of abuse or neglect. Each owner, operator, administrator, employee, or volunteer must fill out this form accurately, as any false information can lead to serious legal consequences, including fines or imprisonment. The form collects essential details such as the individual's name, date of birth, social security number, and current and previous addresses. Additionally, it inquires about the individual's history regarding child abuse or neglect findings, ensuring that the Department of Children and Family Services (DCFS) can maintain a safe environment for children. The licensed facility is responsible for keeping this form on file in compliance with state licensing standards. Understanding the significance of this form is vital for anyone working in or considering a role in child care or juvenile detention in Louisiana.

Document Example

SCR-1 LIC

Rev. 01/13

06/11 Issue Obsolete

STATE OF LOUISIANA

DEPARTMENT OF CHILDREN AND FAMILY SERVICES STATE CENTRAL REGISTRY DISCLOSURE FORM

This form must be completed by each individual owner, operator, administrator, current or prospective employee or volunteer of a child care facility or juvenile detention facility licensed by the Louisiana Department of Children and Family Services for themselves. Any owner, operator, administrator, current or prospective employee, or volunteer of a child care facility or juvenile detention facility licensed by the department who knowingly falsifies the information on the State Central Registry Disclosure Form shall be guilty of a misdemeanor offense and shall be fined not more than five hundred dollars, or imprisoned for not more than six months, or both. R.S. 46:1414.1.C or R.S. 15:1110.2(C).

This form shall be maintained by the owner/operator of the licensed facility in accordance with current licensing standards as mandated by R.S. 46:1414.1.B or R.S. 15:1110.2(B).

Name of Licensed Facility (Print or Type)

Physical Address of Licensed Facility

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual/Applicant (Print or Type)

 

 

 

 

 

Date of Birth

 

 

 

Social Security #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden, Previous or Any Other Name Used

 

 

 

 

 

Race

 

 

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Street Address

 

 

 

 

 

 

 

City and State

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Most Recent Previous Address

 

 

 

 

 

 

City and State

 

 

 

 

 

Zip Code

(

)

-

 

 

 

(

)

-

 

 

 

 

 

 

(

)

-

 

 

Current Home Phone #

 

 

 

Current Cell Phone #

Work Phone #

 

 

 

 

My name

is

is not

currently recorded as a perpetrator on the State Central Registry for what the

 

 

(check one)

Department of Children and Family Services (DCFS) has determined to be a justified

 

 

 

 

(valid) finding of child abuse or neglect.

 

 

 

 

 

 

I

have

have not

been determined to have a justified (valid) finding of abuse or neglect since the Risk

 

 

 

 

Evaluation Panel finding.

 

 

 

 

 

 

 

 

 

 

 

 

 

If the DCFS Licensing Section has reasonable suspicion or is provided with facts or information that your name is on the State Central Registry as a perpetrator with a valid/justified finding of abuse and/or neglect, the Licensing Section may request a clearance of the SCR without your permission. If your name does in fact appear on the SCR as described above, the department will notify both your employer (the facility named above) and the appropriate District Attorney’s office of your failure to comply with R.S. 46:1414.1 or R.S. 15:1110.2.

The information given is true and complete to the best of my knowledge.

Signature

 

Date

 

 

 

Signature of Licensed Facility Representative

 

Date

Dos and Don'ts

When filling out the Louisiana Central Registry form, it is crucial to approach the task with care. Here are some important dos and don'ts to consider:

  • Do read the entire form carefully before starting to fill it out.
  • Do provide accurate and complete information for all required fields.
  • Do ensure that your signature matches the name provided on the form.
  • Do double-check your Social Security number for accuracy.
  • Don't leave any sections blank unless instructed otherwise.
  • Don't provide false information or omit any relevant details.
  • Don't forget to include any maiden or previous names used.
  • Don't submit the form without reviewing it for errors.

By following these guidelines, you can help ensure that your submission is processed smoothly and without unnecessary delays.

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Detailed Instructions for Filling Out Louisiana Central Registry

After completing the Louisiana Central Registry form, it will be submitted to the appropriate authorities as part of the licensing process for child care or juvenile detention facilities. This form is essential for ensuring the safety and well-being of children in these environments.

  1. Obtain a copy of the Louisiana Central Registry Disclosure Form (SCR-1 LIC Rev. 01/13).
  2. Fill in the Name of Licensed Facility field by printing or typing the facility's name.
  3. Provide the Physical Address of Licensed Facility including street address, city, and state.
  4. Enter the License # assigned to the facility.
  5. In the Name of Individual/Applicant field, print or type your full name.
  6. Fill in your Date of Birth in the specified format.
  7. Provide your Social Security #.
  8. List any Maiden, Previous or Any Other Name Used.
  9. Indicate your Race and Sex.
  10. Enter your Current Street Address, including city, state, and zip code.
  11. Provide your Most Recent Previous Address along with city and zip code.
  12. Fill in your Current Home Phone #, Current Cell Phone #, and Work Phone #.
  13. Check the appropriate box to indicate whether your name is currently recorded as a perpetrator on the State Central Registry.
  14. Indicate if you have or have not been determined to have a justified finding of abuse or neglect since the Risk Evaluation Panel finding.
  15. Review the information provided for accuracy and completeness.
  16. Sign and date the form in the designated area.
  17. Have the licensed facility representative sign and date the form as well.

Documents used along the form

The Louisiana Central Registry form is a crucial document for individuals involved in child care or juvenile detention facilities. Along with this form, several other documents are often required to ensure compliance with state regulations. Below is a list of these documents, each serving a specific purpose in the licensing process.

  • Background Check Authorization Form: This form allows the state to conduct a thorough background check on individuals working in child care facilities. It collects consent for the review of criminal history and other relevant records.
  • Child Abuse and Neglect Reporting Form: This document is used to report any suspected child abuse or neglect. It outlines the process for making a report and ensures that allegations are documented properly.
  • Employment Application: This application gathers information about an individual's work history, education, and qualifications. It is essential for evaluating potential employees in child care settings.
  • Training Certification Records: These records confirm that staff members have completed required training in child development, safety, and emergency procedures. They are vital for maintaining licensing standards.
  • Texas Bill of Sale Template: Essential for documenting property ownership transfer, which you can find at Fast PDF Templates.
  • Facility License Application: This application is necessary for obtaining a license to operate a child care or juvenile detention facility. It includes details about the facility's operations, staff, and compliance with safety regulations.
  • Health and Safety Inspection Report: This report documents the results of inspections conducted to ensure that the facility meets health and safety standards. It is crucial for maintaining a safe environment for children.
  • Incident Report Form: This form is used to document any incidents that occur within the facility, including accidents or behavioral issues. Accurate reporting is essential for compliance and accountability.
  • Child Care Policy Manual: This manual outlines the policies and procedures of the facility. It serves as a guide for staff and ensures that all operations align with state regulations.

Each of these documents plays a vital role in maintaining the integrity and safety of child care and juvenile detention facilities in Louisiana. Ensuring that all forms are completed accurately and submitted on time is essential for compliance and the well-being of the children in care.

Your Questions, Answered

What is the purpose of the Louisiana Central Registry form?

The Louisiana Central Registry Disclosure Form is designed to collect essential information from individuals involved in child care facilities or juvenile detention centers. This includes owners, operators, administrators, employees, and volunteers. The form helps ensure that individuals working with children have not been found guilty of child abuse or neglect, thereby promoting the safety and well-being of children in these environments.

Who needs to complete the Louisiana Central Registry form?

Every individual who is an owner, operator, administrator, current or prospective employee, or volunteer at a licensed child care facility or juvenile detention facility in Louisiana must complete this form. This requirement applies to both current staff and those seeking employment or volunteer opportunities in these settings.

What happens if someone provides false information on the form?

Providing false information on the Louisiana Central Registry form is a serious offense. If an individual knowingly falsifies any details, they may face misdemeanor charges. Penalties can include a fine of up to five hundred dollars, imprisonment for a maximum of six months, or both, as stipulated in Louisiana Revised Statutes.

How is the information on the form maintained?

The owner or operator of the licensed facility is responsible for maintaining the completed form in accordance with Louisiana's licensing standards. This ensures that accurate records are kept, which can be reviewed by regulatory authorities as needed.

What information is required on the form?

The form requires various personal details, including:

  • Name of the individual/applicant
  • Date of birth
  • Social Security number
  • Race and sex
  • Current and previous addresses
  • Contact numbers (home, cell, and work)

Additionally, individuals must disclose whether they have been recorded as a perpetrator on the State Central Registry for justified findings of child abuse or neglect.

What is the significance of the 'justified finding' statement?

The statement regarding justified findings of child abuse or neglect is crucial. It allows the Louisiana Department of Children and Family Services (DCFS) to assess an individual's suitability for working with children. If an individual has a justified finding, this information can impact their employment or volunteer opportunities in child care settings.

Can the DCFS access the Central Registry without permission?

Yes, the DCFS Licensing Section can request a clearance of the State Central Registry without the individual's permission if there is reasonable suspicion or credible information that the individual is listed as a perpetrator with a valid finding of abuse or neglect. This process is in place to protect the safety of children in care.

What should individuals do if they have questions about the form?

If individuals have questions or need clarification about the Louisiana Central Registry form, they should contact the Louisiana Department of Children and Family Services. The department can provide guidance and assistance regarding the completion of the form and any related inquiries.

Common mistakes

Filling out the Louisiana Central Registry form can be straightforward, but mistakes can lead to complications. One common error is failing to provide complete and accurate personal information. This includes not only your name and address but also your Social Security number and date of birth. Incomplete information can delay the processing of your application or even result in denial.

Another mistake people often make is neglecting to check all applicable boxes regarding past findings of abuse or neglect. It's crucial to be honest about any justified findings. Misrepresenting this information can lead to serious consequences, including fines or imprisonment. The form requires clarity, so ensure you answer each question fully.

Some individuals overlook the importance of including all previous names used. If you have changed your name, whether through marriage or other means, it is vital to list these accurately. Omitting this information can cause confusion and may result in your application being flagged for further review.

Additionally, many applicants forget to provide current contact information. This includes home, cell, and work phone numbers. If the Department of Children and Family Services needs to reach you for clarification or additional information, having accurate contact details is essential. Without this, communication can break down, causing further delays.

Finally, a frequent oversight is not signing the form. Both your signature and the signature of the licensed facility representative are required. A missing signature can render the form incomplete, leading to processing issues. Review the form carefully before submission to ensure all necessary fields are filled out and signed.

Misconceptions

Misconception 1: The Louisiana Central Registry form is only for employees.

This form must be completed by all individuals associated with a child care or juvenile detention facility, including owners, operators, administrators, and volunteers. It is not limited to just employees.

Misconception 2: Falsifying information on the form is a minor issue.

In fact, knowingly providing false information on the State Central Registry Disclosure Form is a serious offense. It can lead to a misdemeanor charge, with penalties including fines up to five hundred dollars or imprisonment for up to six months.

Misconception 3: The form is optional for licensed facilities.

Completion of the form is mandatory for all licensed child care and juvenile detention facilities. It must be maintained according to current licensing standards as required by Louisiana law.

Misconception 4: If my name is not on the registry, I do not need to worry.

Even if your name is not currently listed, the Licensing Section can still investigate if there is reasonable suspicion or information suggesting you may be a perpetrator. Your employer and the District Attorney’s office will be notified if any issues arise.

Document Attributes

Fact Name Description
Purpose of the Form This form is required for individuals involved with child care or juvenile detention facilities licensed by the Louisiana Department of Children and Family Services.
Legal Consequences Providing false information on the form can result in misdemeanor charges, with potential fines up to $500 or imprisonment for up to six months, or both.
Governing Laws The form is governed by Louisiana Revised Statutes R.S. 46:1414.1.C and R.S. 15:1110.2(C).
Record Maintenance Licensed facilities must maintain this form in accordance with current licensing standards as per R.S. 46:1414.1.B and R.S. 15:1110.2(B).
Information Verification The Licensing Section may request a clearance of the State Central Registry without the individual's permission if there is reasonable suspicion of abuse or neglect findings.