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I'-.. I'' ',,, V "'.., t ... ' .--... ,vJ ~, ~ L'\ "\7 ~ """--~" {/J1 y - \ --..___/J Y'-.' ~ rl "';" ..... r , , i, J-....., V A ~ "~ "-'-._(( "-' . ,, V L) 'y tr ~I y \~ /J h~'-/ (I._,"''"" ,v ~ t~ r t:. ... ~ ...... "' ~ I~ ''1 r"'-."'.. n -........_ ~ ----~ fv ~( \~ )/ CCA-1211B FORNA (4-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration (CCA) ATTACHMENT TO REQUEST FOR SEARCH OF BACKGROUND CHECKS (CCA-1211AFORNA) DISQUALIFICATION ACTS A person is disqualified from providing services to ADES clients in a direct service position if he/she is identified as the subject of the substantiated report for any of the following. Code Definition 24 Child death due to alleged abuse or neglect, or suspicious death 25 Injuries requiring emergency medical treatment 27 Child age 24 months is shaken (shaken baby syndrome) 33 Untreated life threatening condition, Infant Doe, Non-organic FTT 37 Imminent harm to child under the age of six (6) due to lack of supervision by parent/caretaker 38 Neglect results in injury/illness requiring emergency medical treatment 39 Imminent harm to child due to health or safety hazards in living environment/exposure to the elements 40 Child diagnosed as suicidal by mental health professionals, parent refused to allow treatment 41 Physical evidence of sexual abuse reported by a medical doctor or child reporting sexual abuse within the past seven (7) days 42 Child reporting vaginal or anal penetration or oral sexual contact within past 72 hours and has been examined 43 Abandoned, no parent willing to provide immediate care for a child and child is with a caregiver unable or unwilling to provide care now 45 Injuries may require medical treatment 46 P3 Injury to child under age six (6) years 50 Living environment presents health or safety hazards to a child under the age of six (6) 51 Sexual conduct/physical injury between children due to inadequate supervision 54 Sexual behavior within the past 8-14 days 55 Child diagnosed by mental health professional with behavior consistent with emotional abuse 56 Abandoned, no parent willing to care for a child, child with caretaker unable or unwilling to care for child less than one (1) week 66 Significant developmental delays due to neglect 69 Attempted sexual behavior or sexual behavior, 14 days to three (3) years or last occurrence unknown 72 Parent, guardian or custodian suggests or entices child to engage in sexual behavior, no touching 76 Use of child by parent, guardian or custodian for material gain 82 Parent, guardian or custodian sexually abused a child in past, now in home with a child 83 Attempted sexual behavior or sexual behavior when last occurred more than three (3) years 101 Death of a child due to neglect 111 Death of a child due to physical abuse or suspicious death 201 Physical abuse high risk 202 Physical abuse moderate risk 301 Neglect, high risk 302 Neglect, moderate risk 401 Sexual abuse, high risk 402 Sexual abuse, moderate risk 403 Sexual abuse, low risk 404 Sexual abuse, response 4 501 Emotional abuse, high risk 502 Emotional abuse, moderate risk CCA-1211B (4-16) – Page 34