Report Of Law Enforcement Contact
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1Division of Public Health - Licensure Unit - Children's Services Licensing Program
Report of Law Enforcement Contact
INSTRUCTIONS: This form must be completed by the applicant/licensee and each staff member and each household member
that is 19 years of age or older. All felonies, misdemeanors and infractions must be reported regardless of age of the individual at
the time of the incident or contact by law enforcement. Minor traffic violations do not need to be reported. Law enforcement contact
means that an arrest occurred or a citation/ticket was issued by a police officer. Staff member includes substitutes, volunteers,
primary providers, secondary providers, director, co-director, teacher, certificated/non-certificated teachers, any individual who
counts in the staff-child ratio, and any individual who may have contact with children, i.e., aide, cook, driver, or volunteer. Having a
conviction does not necessarily prevent you from obtaining a license.
Have you ever:
Yes
No
1.
Been arrested or cited by any law enforcement officer (includes local, county, state or federal)? ..................
2.
Been arrested or cited by any law enforcement officer in another state? .......................................................
3.
Been arrested or cited but charges were dismissed or not filed? ...................................................................
4.
Been charged with committing any misdemeanor crime? ..............................................................................
5.
Been charged with committing any felony crime? ...........................................................................................
6.
Been convicted, pled guilty or pled no contest to any felony and/or misdemeanor crime?.............................
7.
Been convicted, pled guilty or pled no contest to a crime against children? ..................................................
8.
Been on a suspended sentence, such as diversion, probation or parole? .....................................................
9.
Been in jail or prison? .....................................................................................................................................
10.
Been charged with any crime that is sexual in nature? ...................................................................................
If you answered "yes" to any of the above questions, you must complete the following table (if you need more space, please
use an additional form). Law enforcement records may be obtained in order to determine the accuracy of your answers.
Incident
Description
Felony,
County
Outcome/Disposition
Date
of
Misdemeanor
and
(i.e., jail, fine, probation,
mm/dd/yy
Charge
or Infraction
State
dismissed, diversion, etc.)
To the best of my knowledge, the information provided above is true and accurate. I understand that failure to accurately
report may result in negative or disciplinary action as determined by the Department.
_________________________________________
________________________
____________________________________
Signature
Date of Birth
Relationship to Facility
________________________________________
_______________________________________________________________
Printed Name
Other Names Used (previous married, maiden, alias, nicknames)
(If no other names have been used, indicate "none")
________________________________________
_________________________
____________________________________
Name of Facility/Provider
Telephone Number
Date
Distribution: WHITE - Central Office; CANARY - Children's Services Licensing; PINK: Provider/Applicant
CRED-0600 Rev. 4/13 (56003)
(Previous version should not be used)
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