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CCA-1211A FORNA (4-16) This document and any files transmitted with it are confidential and intended solely for the use of the individual or entity to which they are addressed. If you have received this information in error, please notify the sender and destroy the information. Arizona Department of Economic Security (ADES) Child Care Administration (CCA) Provider Contracts Unit REQUEST FOR SEARCH OF BACKGROUND CHECKS The information contained in the Central Registry of Arizona Department of Child Safety (ADCS), and any attached files shall be used as a factor to determine qualifications for individuals applying for contracts with this state, including employees of the prospective contractor, contractors, and subcontractors for positions that provide direct services to children. The information contained in the ADCS Central Registry and any attached files are confidential and shall not be further disseminated or shared. SPECIAL NOTE: In order to adhere to confidentiality requirements, this document can only be completed by either the owner or the individual responsible for hiring staff and volunteers for this facility. Please PRINT or TYPE the information accurately and completely in all the fields below and on the subsequent pages. P r o v i d e r Information for Request for Search of Background Checks SUBMIT YOUR COMPLETED REQUEST THROUGH ONE OF THE FOLLOWING METHODS: Mail to: CCA Background Investigation Unit Attention: Francesca Romero Post Office Box 6123 S/C 944C Phoenix, AZ 85005 OR Email [secured] to: CCACentralRegistry@azdes.gov Faxed request documents will NOT BE ACCEPTED or PROCESSED. You will receive an emailed response which contains one or more of the following results. • Unable to process • All staff cleared • Substantiated finding (non-disqualifying) • Substantiated finding (disqualifying) – [A list of the Disqualification Acts is attached for your information.] • Substantiated finding (disqualifying with exception granted) F O R INTERNAL USE ONLY EOE/ADA/LEP/GINA disclosures located on attached Disqualification Acts page CCA-1211A (4-16) – Page 32 Page 1 of ______ Arizona Department of Economic Security