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CCA-1212A FORNA (4-16) EMPLOYERS: Please retain this form in your confidential files. Please DO NOT submit to ADES. ARIZONA DEPARTMENT OF ECONOMIC SECURITY (ADES) Child Care Administration (CCA) Provider Contracts Unit DIRECT SERVICE POSITION (Certification form) You are being provided this form because you have applied for a position that provides direct services to children of the Arizona Department of Economic Security (ADES). Arizona state law requires that all individuals who provide direct services to children certify whether an allegation of abuse or neglect was made against them and was substantiated. Your information, upon submission by your employer, will be searched through the Arizona Department of Child Safety (ADCS) Central Registry as well as the following local and national registries of any state in which you have resided in the previous five (5) years: Criminal and Sex Offender, Child Abuse and Neglect, National Crime Information Center (run by the FBI), FBI Fingerprint Check using Next Generation Identification, and National Sex Offender. All information contained on this form is confidential and will be retained as such by your employer. C e r t i f i c a t i o n

I n f o r m a t ion

f o r

D i r ec t S e r vi c e

P o s i t i o n Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. Disponible en español en la oficina local. CCA-1212A (4-16) – Page 36 Arizona Department of Economic Security