Form Cca-1228a Forff - Provider Home Certification Direct Service Position (Certification Form)
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1228A FORFF (12-16)
Child Care Administration
PROVIDER HOME CERTIFICATION
DIRECT SERVICE POSITION (Certification form)
You are being provided this form because you or a household member 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 individu-
als 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, 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.
LAST NAME
FIRST NAME
FULL MIDDLE NAME (No initials unless name is initial only)
ALL PREVIOUS NAMES (such as maiden, prior marriages, nick names.)
SEX
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
Male
Female
PHYSICAL ADDRESS (No., street, city, state, zip code)
•Have you lived in other state(s) in the past five (5) years?
If Yes, please complete the Direct Service Position Supplement #1 form.
No
Yes
•Are you currently the subject of an investigation of child abuse or neglect in Arizona or another state or jurisdiction?
No
Yes
•Have you ever 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?
If Yes, please answerthe following questions. If you need additional space,
No
Yes
please use the Direct Service Position Supplement #2 form.
When was/were the investigation(s) conducted?
Where was/were the investigation(s) conducted?
What was/were the allegations? (Please print or type.) Do not include the name of any child or person involved in
the investigation.
Direct Service Position Supplement #2 attached
No
Yes
STATEMENT OF CERTIFICATION
By signing this form and any supplement(s), if applicable, I certify that the information provided is true, correct, and com-
plete to the best of my knowledge and belief.
SIGNATURE
DATE
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, dis-
ability, genetics and retaliation. 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.
• Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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