Form Fbu-1003aforff - Direct Service Position
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FBU-1003AFORFF (5-17)
Division of Employment & Rehabilitation Services
DIRECT SERVICE POSITION
You have applied for a position that provides direct services to children or vulnerable adults. Arizona Revised Statutes
(ARS §
8-804.I) require you to certify, under penalty of perjury, whether an allegation of abuse or neglect was made
against you and was substantiated. If your certification does not indicate a current investigation or a substantiated report
of abuse or neglect, your employer may permit you to provide direct services pending the findings of a Central Registry
Background Check by the Division of Employment & Rehabilitation Services. Your employer is required to keep this form
and all information provided on it as confidential.
NAME (Last, First, M.I.)
SOC. SEC. NO.
ALIASES (Maiden, nicknames, etc.)
DATE OF BIRTH
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
Are you currently the subject of an investigation of child abuse or neglect in Arizona, or another state or jurisdiction?
Yes
No
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?
Yes
No
If Yes, to the question immediately above:
What was the allegation(s)?
When was the investigation(s) conducted?
Where was the investigation(s) conducted?
If you wish to provide additional information see Direct Service Position Supplement
STATEMENT OF CERTIFICATION
By signing this form, I certify that the information provided is true, correct, and complete to the best of my knowledge and belief.
SIGNATURE:
DATE:
Employers: Please maintain this form as confidential.
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. To request this document
in alternative format or for further information about this policy, contact your local office; 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 está
disponible a solicitud del cliente.
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