838 Sfn00838
User Manual: 838
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PERSONAL AUTHORIZATION FOR CRIMINAL HISTORY BACKGROUND CHECK INQUIRY NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES CHILDREN AND FAMILY SERVICES-CBCU SFN 838 (12-2017) Children and Family Services-CBCU North Dakota Dept. of Human Services 600 E Boulevard Ave Dept 325 Bismarck ND 58505-0250 dhscfscbc@nd.gov FAX: 701-328-0358 ATTENTION APPLICANT Should you, as a prospective: adoptive parent; provider for foster care facility, foster home care, kinship care, relative care; LCPA employee; or legal guardian of children, are age 18 or older and choose to initiate a criminal history background check through the NDDHS, Children & Family Services Division, Criminal Background Check Unit (CBCU), please review the following information and complete as directed. The Personal Authorization for Criminal History Background Inquiry Form (SFN 838) http://www.nd.gov/eforms/Doc/ sfn00838.pdf and the Criminal History Background Check Address Disclosure/Release of Information Form (SFN 377) http://www.nd.gov/3forms/Doc/sfn00377.pdf are available as fill-able, printable e-forms and are the only forms accepted by the CBCU to initiate a criminal history background check. To eliminate the issue of illegible forms, applicants are encouraged to complete all forms by using either the fill-able, printable e-forms option (preferred method); or to complete applicant forms by typing or printing information. Required information: Completed SFN 838, Completed SFN 377, and either (a): LiveScan fingerprint submission (preferred method) conducted by a trained Scanner Operator from any of the (8) Regional Human Service Centers; law enforcement personnel or other BCI-trained official; or (b) (2) inked fingerprint cards. If applicant chooses to have inked fingerprint cards rolled by law enforcement personnel or other BCI-trained official, agency contact must provide applicant with (2) program-specific blank fingerprint cards/envelope (supplied by CBCU) to bring to their fingerprinting appointment. Applicant information on fingerprint cards must be completed in black ink only. Marker/highlighter cannot be used on the fingerprint cards. To prevent instances of applicants tampering with completed inked fingerprint cards, officials rolling fingerprints will seal applicants inked fingerprint cards within envelope and affix their agency stamp or official signature to envelope/envelope flap before handing over to applicant. Applicant must return the sealed envelope to agency contact for submission to CBCU. NOTE TO APPLICANT/AGENCY CONTACT Review each section of forms for legibility and accuracy in completion to prevent a delay in processing of criminal history background check. Please Note: All applicant forms will be returned unprocessed by CBCU to the initiating agency/ agency contact for required action if: 1) applicant, as applicable, has self-disclosed arrest(s), conviction(s), confinement, and/or dismissal(s) in any state, city, federal, tribal court or military process or indicates they have been the subject of child abuse/neglect reports(s) but fails to provide complete information (including name of state(s), date(s) and explanation of incident(s); 2) date applicant signs forms and the date their forms are received in the CBCU is greater than 10 working days; 3) any section of the SFN 838 and/or the SFN 377 is illegible, incomplete, or contains information inconsistent with data listed on fingerprint cards. Processing Fees: NDDHS pays all criminal background check related applicant fees for Foster Care (and related programs), Guardianship, or LCPA Employees. Prospective adoptive parents, as well as individual's pursuing private guardianship, are required to submit a check or money order in the amount of $40.00 payable to the NDDHS when requesting a fingerprint-based criminal background check or a $15.00 per applicant fee when requesting a ND (BCI only) criminal records search. Please note: the ND (BCI only) records search is considered a sufficient applicant criminal records search only when used in conjunction with an adoption study update or an international adoption. When applicable, additional incidental fees may apply for out of state Child Protective Service Index searches and/or any drivers record checks. YOUR RIGHTS AND RESPONSIBILITIES The Privacy Act of 1974 (P.L. 93-579, Section 7) requires that the following information be provided when individuals are requested to disclose their social security number: Disclosure of the social security number is voluntary and is requested for the purpose of conducting a criminal history background check. Failure to disclose this information may affect the applicants ability to become a licensed foster parent; to be employed in a foster care facility; to become an appointed legal guardian of children; to be employed in a licensed child placing agency; to be approved for adoption. I understand that as a person who is subject to a criminal history background check, I am entitled to: (a) obtain a copy of any criminal background check report from the Bureau of Criminal Investigation (BCI) or the Federal Bureau of Investigation (FBI) by following their record request procedures; (b) obtain a copy of the child abuse & neglect index registry check report; (c) challenge the accuracy and completeness of any such report (in the jurisdiction involved with the charge or conviction); and (d) obtain a prompt resolution before a final determination is made by the authorized agency. Your fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI). You have the opportunity to complete or challenge the accuracy of the information contained in the he FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set for in Title 28 C.F.R. § 16.34. For the Foster Care Program, this application and the results of the criminal background check are a public document and must be made available upon request. Information may be redacted pursuant to state and federal statute and rule. SFN 838 (12-2017) Page 2 of 4 As A Prospective Provider for Foster Care Facility, Foster Home Care, Kinship/Relative Care Facility Staff: I understand that a foster care facility/agency, as a qualified entity, shall request a criminal history background check pursuant to NDCC Ch. 50-11 and 50-11.3. I understand that prior to the completion of the criminal history background check, the foster care facility may choose to deny me unsupervised access to a person to whom the foster care facility provides care. I further understand the foster care facility may choose to deny employment if I provide false or misleading information or intentionally withhold information regarding my criminal history. I understand that completion of the SFN 838 “Personal Authorization for Criminal History Background Check Inquiry” is a required step to gain employment at a foster care facility for children pursuant to NDCC Ch. 50-11. Foster Parent, Kinship or Relative Care Provider and Adults Residing in Caregiving Home: I understand that an agency, as a qualified entity conducting a home assessment for a foster care home, shall request a criminal history background check pursuant to NDCC Ch. 50-11 and 50-11.3. I understand that completion of the SFN 838 “Personal Authorization for Criminal History Background Check Inquiry" is a required step for licensure as a foster care home for children pursuant to NDCC Ch. 50-11. A foster care license may be revoked or denied in accordance with NDCC Ch. 50-11 if issued upon false, misleading material information, or you intentionally withhold material information. As A Prospective Legal Guardian of Children I understand that an agency conducting a home assessment for prospective legal guardianship of a child shall request a criminal history background check pursuant to NDCC Ch. 50-11.3. I further understand that before I can be appointed as legal guardian to children pursuant to NDCC 27-20, I am subject to an assessment pursuant to NDCC 50-11.3-01. I understand that completion of the SFN 838 “Personal Authorization for Criminal History Background Check Inquiry" is a required step in the application for guardianship of children pursuant to NDCC Ch. 50-11. As A Prospective LCPA Employee I understand that a Licensed Child Placing Agency, as a qualified entity in relation to foster care and adoption programs, shall request a criminal history background check pursuant to NDAC 75-03-36-12. I further understand that prior to the completion of the criminal history background check, the LCPA shall choose to deny me unsupervised contact with clients. I understand that completion of the SFN 838 "Personal Authorization for Criminal History Background Check Inquiry" is a required step to gain employment in a LCPA. I further understand that pursuant to NDAC 75-03-36-13 (4), the department may deny a request for criminal background check for any individual who provides false or misleading information about the individual's criminal history. As A Prospective Adoptive Parent I understand that a licensed child-placing agency, as a qualified entity, shall request a criminal history background check pursuant to NDCC Chapter 50-12. I further understand that prior to the completion of the criminal history background check, the qualified entity may choose to deny me unsupervised access to a person to whom the qualified entity provides care. I understand that completion of the SFN 838 “Personal Authorization for Criminal History Background Check Inquiry" is a required step in the pre-placement adoptive home study report. I further understand that pursuant to NDAC 75-03-36-13(4), the department may deny a request for a criminal background check for any individual who provides false or misleading information about the individuals criminal history. PERSONAL AUTHORIZATION FOR CRIMINAL HISTORY BACKGROUND CHECK INQUIRY NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES CHILDREN AND FAMILY SERVICES-CBCU Clear Fields SFN 838 (12-2017) Applicant's Photo ID Check: (must be verified by Scanner Operator or Official rolling prints) ID Used: Driver's License or State ID Passport Tribal or Military ID Legal Authority: NDCC 50-11 (Foster Care Services), NDCC 50-11.3-01 (Legal Guardian of a Child), NDCC 50-12 (Adoption), NDAC 75-03-36-12 (LCPA) all provide for a fingerprint based criminal history background check. REQUIRED INFORMATION TO BE COMPLETED BY AGENCY Agency means a county social service agency conducting a licensing study for foster care or otherwise requesting a criminal records check in order to place a child; a private licensed child placing agency; or a foster care or residential treatment facility. Attention: When selecting program type below (Adoption; Foster Care Related Program or LCPA Employee), check ONLY ONE box per SFN 838 Authorization Foster Care Related Program Adoption Special Needs Adoption Domestic Adoption International Adoption Home Assessment Update Hague Convention Agency: Contact Person: Address: City: Foster Home Relative Care Kinship Care Guardianship LCPA Employee New (hired after 4/1/10) RCCF PRTF Group Home Volunteer Email Address of Contact Person: State: Telephone Number: ZIP Code: REQUIRED INFORMATION TO BE COMPLETED BY APPLICANT OR ADULT RESIDING IN CAREGIVING HOME Full Legal LAST Name: Name FIRST Name: FULL MIDDLE Name: None Social Security Number: Birth Name FIRST Name: FULLMIDDLE Name: None Date of Birth: LAST Name: Other Married (LAST Name(s)): Current Physical Address: * Gender: M F Aliases, Nicknames: City: State: ZIP Code: Telephone Number: PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND CHECK ONE BOX FOR EACH SET OF STATEMENTS: 1. I have OR I have not resided in North Dakota at all times in the past five years 2. I have never been the subject of any child abuse/neglect reports in any state; OR I have been the subject of a child abuse/neglect report(s). I understand that I must provide the name of the state(s), date(s) and complete description of the incident(s) or my paperwork will be returned, unprocessed, to agency contact listed above. 3. I have never been arrested or convicted of any crimes in any state, city, federal, tribal court or military process; OR I have been arrested or convicted of a crime(s) in any of the courts or processes named above. I understand that I must provide a complete description of my crime(s); including date(s) and city/county/state(s), along with details surrounding my arrest(s); conviction(s), confinement(s) and/or dismissal(s) or my paperwork will be returned, unprocessed, to agency contact listed above. I give the North Dakota Department of Human Services permission to: (1) use my fingerprints and the information on this form as a means of searching for my name on the National Crime Information Database; (2) search for my name on the North Dakota Child Abuse/Neglect Index or any state's Child Abuse/Neglect Central Registry or through any tribal court or Indian child welfare agency; (3) search for my name on the North Dakota or any state's sex offender or offender against children registry; (4) request any supplemental documentation about me related to any offense revealed through the course of this criminal background records check; (5) share any relevant information derived from any source with any authorized child welfare agency or early childhood services program indicated above. I understand that an application may be denied if it contains false or misleading material information or if I intentionally withheld material information. Furthermore, I understand that: Based on NDCC 12.1-11-02. False Statements. (2) A person is guilty of a class A misdemeanor if, in a governmental matter, he: a. Makes a false written statement, when the statement is material and he does not believe it to be true; b. Intentionally creates a false impression in a written application for a pecuniary or other benefit, by omitting information necessary to prevent a material statement therein from being misleading; I certify that all information I have provided on this form is true and correct to the best of my knowledge. I certify that all statements on this form have been read by me or read to me and I understand all the questions. Signature of Applicant: Date: SFN 838 must be received in CBCU within 10 working days from date signed by applicant. (Note: Applicant may need to re-sign/re-date SFN 838 to fulfill this requirement) Fingerprint ID Number (PCN) For Scanner Operator Use Only: * See Page 4, Your Rights and Responsibilities SFN 838 (12-2017) Page 4 of 4 Use this space to expand the explanations or information related to questions from page 3 I certify that all the information I have provided on this form is true and correct to the best of my knowledge. I certify that all statements on this form have been read by me or read to me and I understand all the questions. Signature of Applicant: Date: SFN 838 must be received in CBCU within 10 working days from date signed by applicant. (Note: Applicant may need to re-sign/re-date SFN 838 to fulfill this requirement) RIGHTS AND RESPONSIBILITIES *TheYOUR Privacy Act of 1974 (P.L. 93-579, Section 7) requires that the following information be provided when individuals are requested to disclose their social security number: Disclosure of the social security number is voluntary and is requested for the purpose of conducting a criminal history background check. Failure to disclose this information may affect the applicants ability to become a licensed foster parent; for employment at a foster care facility; for employment at a licensed child placing agency; to become an appointed legal guardian of children, to be approved for adoption. DISTRIBUTION OF SFN 838 If Electronic Fingerprint Submission: Scanner Operator: Scan SFN 838 (pages 3 and 4 only), and submit to DHS Criminal Background Check Unit via Group EMail Address - dhscfscbc@nd.gov If Inked Fingerprint Submission: Two Signed Copies to DHS Criminal Background Check Unit Mail to: Children and Family Services-CBCU North Dakota Dept. of Human Services 600 E Boulevard Ave Dept 325 Bismarck ND 58505-0250
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