Name Relationship to SSN Local FSFN NCIC and Fingerprints Other States Cleared Disqualifying Caregiver Verified Background FCIC Received Checks Offenses (5 years) Yes No Y N Y N Y N Y N Y N Y N Y N Date: Date: Date: Date: Date: Yes No Y N Y N Y N Y N Y N Y N Y N Date: Date: Date: Date: Date: Yes No Y N Y N Y N Y N Y N Y N Y N Date: Date: Date: Date: Date: Yes No Y N Y N Y N Y N Y N Y N Y N Date: Date: Date: Date: Date: Additional background checks not listed above [include name of check, (e.g. DJJ, driving record, civil court) name of individuals screened and date of results]: Background checks for other individuals (Frequent or repeat visitors, other individuals who may have unsupervised contact with child(ren):
Name Relationship to Caregiver SSN Verified Local Background FSFN NCIC and FCIC Fingerprints Received Other States Checks (5 years) Cleared Disqualifying Offenses Yes No Y N Date: Y N Date: Y N Date: Y N Date: Y N Date: Y N Y N Yes No Y N Date: Y N Date: Y N Date: Y N Date: Y N Date: Y N Y N Yes No Y N Date: Y N Date: Y N Date: Y N Date: Y N Date: Y N Y N Yes No Y N Date: Y N Date: Y N Date: Y N Date: Y N Date: Y N Y N Additional background checks not listed above [include name of check, (e.g. DJJ, driving record, civil court) name of individuals screened and date of results]: Background checks for other individuals (Frequent or repeat visitors, other individuals who may have unsupervised contact with child(ren):
FCL_Mod4-PG062714.docx