838 Sfn00838

User Manual: 838

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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.
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
PERSONAL AUTHORIZATION FOR CRIMINAL
HISTORY BACKGROUND CHECK INQUIRY
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
CHILDREN AND FAMILY SERVICES-CBCU
SFN 838 (12-2017)
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.
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.
SFN 838 (12-2017)
Page 2 of 4
Foster Care Related Program
PERSONAL AUTHORIZATION FOR CRIMINAL
HISTORY BACKGROUND CHECK INQUIRY
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
CHILDREN AND FAMILY SERVICES-CBCU
SFN 838 (12-2017)
Clear Fields
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 APPLICANT OR ADULT RESIDING IN CAREGIVING HOME
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND CHECK ONE BOX FOR EACH SET OF STATEMENTS:
I have OR
I have never been the subject of any child abuse/neglect reports in any state; OR
I have never been arrested or convicted of any crimes in any state, city, federal, tribal court or military process; 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.
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.
(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;
Applicant's Photo ID Check: (must be verified
by Scanner Operator or Official rolling prints)
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.
Adoption
Signature of Applicant:
Date:
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.
1.
I have not resided in North Dakota at all times in the past five years
2.
3.
*
See Page 4, Your Rights and Responsibilities
LCPA Employee
Attention: When selecting program type below (Adoption; Foster Care Related Program or LCPA Employee), check ONLY ONE box per SFN 838
Authorization
ID Used:
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)
I give the North Dakota Department of Human Services permission to:
Fingerprint ID Number (PCN)
For Scanner Operator Use Only:
Agency:
Address:
City:
State:
Contact Person:
ZIP Code:
Email Address of Contact Person:
Telephone Number:
Driver's License or State ID
Passport
Tribal or Military ID
Full Legal
Name
Birth
Name
LAST Name:
LAST Name:
Other Married (LAST Name(s)):
City:
FIRST Name:
FIRST Name:
Current Physical Address:
State:
ZIP Code:
FULL MIDDLE Name:
Aliases, Nicknames:
FULLMIDDLE Name:
Date of Birth:
Telephone Number:
Social Security Number:
Gender:
*
M
F
None
None
Special Needs Adoption
Domestic Adoption
International Adoption
Home Assessment Update
Hague Convention
Foster Home
Relative Care
Kinship Care
Guardianship
RCCF
PRTF
Group Home
Volunteer
New (hired after 4/1/10)
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.
SFN 838 (12-2017)
Page 4 of 4
If Electronic Fingerprint Submission:
If Inked Fingerprint Submission:
Two Signed Copies to DHS Criminal Background Check Unit
DISTRIBUTION OF SFN 838
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
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; 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.
*
Children and Family Services-CBCU
North Dakota Dept. of Human Services
600 E Boulevard Ave Dept 325
Bismarck ND 58505-0250
Mail to:
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)

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