Page 43

CCA-1212A FORNA (4-16) Staff Name: Date of Birth: DIRECT SERVICE POSITION SUPPLEMENT #2 [Additional Information Regarding Substantiated Findings] The Direct Service Position Supplement #2 is to be used by individuals who have completed the Direct Service Position form and need additional space in order to answer the question in which they have indicated that they have been the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction that resulted in a substantiated (determined to have occurred) finding. This information will be retained by the Employer as confidential. CONTINUATION: (Please print or type.) What was/were the allegations(s)? Do not include the name of any child or any person involved in the investigation. Page 38 CCA-1212A (4-16) – Arizona Department of Economic Security