Background Screening Forms

Background Screenings

opens in a new tabBackground Screening Application – Adoption (One-time adoption application – no RapBack or Adam Walsh clearance)

One-time Adoption Background Screening Procedure:

Background screenings are required for one-time adoptions. In accordance to UCA62A-2-120 and 78B-6-128, the Office is permitted to accept applications for the purpose of a one-time adoption from a non-licensed entity (adoption attorney, or other). The process for submitting these applications is as follows:

Application: Fill out the application of the adoptive parent for the one-time clearance. The top portion needs to be signed by the applicant, the bottom portion is signed by the non-licensed entity.

Out of State Clearance: Per 62A-2-120 applicants need to receive the Out of State Child Abuse Registry check for any state in which they have resided in the last 5 years. This needs to be obtained prior to submitting the application to the office and the results included with the application to the Office. For information on obtaining the Out of State Registry, visit this link on our website: Out of State Registries.

Submit the fee of $37.25 per application in one of the following forms: Company check, cashier’s check, or money order made payable to Department of Human Services

Fingerprints: Submit 2 correctly-rolled fingerprint cards per applicant to the Office, which we will submit to the Office of Public Safety to fulfill FBI requirements. OR, submit the application, fee, and any other applicable documents, and request the Office send you a fingerprint authorization form for the applicant to be live scanned which will electronically submit the fingerprints. Please be aware if the fingerprint authorization form is requested, the applicant has to wait for the Office to send the form with the fingerprint authorization before they can be live scanned.

Receiving Results: Once the Office reviews this information a determination will be made per 62A-2-120 and emailed from the Office to the email address provided from the non-licensed entity on the Background Screening Application. If the email address is not legible or comes back invalid, it will be sent via USPS to the address listed for the non-licensed entity.

DACS Information and Training Material

opens in a new tabSteps for Entering a Youth Application in DACS

opens in a new tabExemption Declaration (adult substance abuse treatment programs only)

opens in a new tabLivescan locations (non-foster care)

opens in a new tabLivescan locations (foster homes only)

Contact Information for obtaining an out of state Central or Child Abuse Registry Check

opens in a new tabDHS Contractor Background Screenings

FBI NGI Rap Back Privacy Statement

Utah consent to Background Check

I understand that my personal information including name, date of birth, social security number and fingerprints will be used for the purpose of conducting a criminal history records search through any applicable state and federal databases. This information will be used by the Department of Human Services, Office of Licensing to determine my eligibility to have direct access to a child or vulnerable adult. My personal information and fingerprints may be retained for ongoing monitoring and comparison against future submissions to the state, regional or federal database and latent fingerprint inquiries}. The Department of Human Services, Office of Licensing will establish procedures to ensure removal of my fingerprints from applicable state and federal databases when I am no longer under their purview. I understand that I may request to review any results of this inquiry and understand that UCA 53-10-108 does not allow the

Department of Human Services, Office of Licensing to provide a copy of those results to me. Before a determination is made, I understand that I will be afforded a reasonable amount of time to challenge the completeness and accuracy of the record through the procedures established by the Department of Human Services, Office of Licensing as well as contacting the Utah Bureau of Criminal Identification (Utah Criminal History Results), the State Identification Bureau (SIB) associated with any results that are outside of Utah, or the Federal Bureau of Investigation (Nationwide Criminal History Response Information). I have read the attached Privacy Statement and understand my rights according to this statement.

FBI Privacy Act Statement

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date.

Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or

voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).

Challenge procedures: State of Utah:

The Utah Bureau of Criminal Identification is responsible for all arrest and conviction data for the State of Utah. BCI does not have the authority to modify any records from other state or federal databases. In the event that there is incorrect or missing Utah Criminal Data, please be prepared to provide certified copies from any arresting agency or court of appearance.

To challenge State of Utah criminal arrests and disposition data please complete the required application and submit to the Utah Bureau of Criminal Identification. Instructions and applications are located at the following web address:

opens in a new tabhttps://bci.utah.gov/wp-content/uploads/sites/15/2017/08/ROA-8-24-2017.pdf

FBI:

opens in a new tabhttps://www.fbi.gov/services/cjis/identity-history-summary-checks Challenge of an Identity History Summary

The FBI is responsible for the storage of fingerprints and related Identity History Summary information for the nation and does not have the authority to modify any Identity History Summary information unless specifically notified to do so by the agency that owns the information. If you believe your Identity History Summary contains inaccurate or incomplete information, you have two options for requesting a change or correction:

Option 1: Contact the agency or agencies that submitted the information to the FBI. Missing or Incorrect State (Non-Federal) Information

Most states require that changes to Identity History Summary information be processed through their respective state centralized agency (State Identification Bureau) before any changes can be made to your information. You may contact the respective State Identification Bureau for assistance, and, if applicable, request that they provide the FBI with updates to your Identity History Summary. Contact information for each state is provided on the State Identification Bureau listing.

Several states maintain their own record system. Record updates are made at the state level only, so the FBI cannot change its records. Instead, the FBI accesses the state’s system for authorized purposes to review the record. Contact information for states maintaining records at the state level is provided on the State-Maintained Records listing.

Missing or Incorrect Federal Information

For federal Identity History Summary updates, the FBI must receive a request directly from the original arresting agency, from a court with control over the arrest data, or from another agency with control over the arrest data.

Option 2: Send a written challenge request to the FBI.

Your written request should clearly identify the information that you feel is inaccurate or incomplete and should include copies of any available proof or supporting documentation to support your claim. For example, if your disposition information is incorrect or missing, you may submit documentation obtained from the court having control over the arrest or the office prosecuting the offense. The FBI will contact appropriate agencies in an attempt to verify or correct challenged entries for you. Upon receipt of an official communication from the agency with control over the data, the FBI will make appropriate changes and notify you of the outcome.

You may submit an Identity History Summary challenge to the FBI by writing to the following address:

FBI CJIS Division

Attention: Criminal History Analysis Team
1 1000 Custer Hollow Road
Clarksburg, WV 26306