Criminal History Evaluation Form

TITLE 89: SOCIAL SERVICES CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES PART 415 RELATIVE HOME CERTIFICATION SECTION 415.170 CRIMINAL HISTORY EVALUATION FORM Section 415.170  Criminal History Evaluation Form Once a background check has been completed for a relative caregiver applicant or another adult living in the home, if the individual has a criminal history, that history shall be evaluated using an evaluation form. Only a Department-issued official form with a CFS number in the top left-hand corner shall satisfy the requirements of this Part. The form shall consist of the following elements: a)         The title, which will be: "Criminal History Evaluation Form". b)         Instructions, which will include the following information: "Use this form to evaluate whether to waive child abuse, neglect, or criminal history for a relative caregiver applicant or another adult living in the home. Federally disqualifying crimes may not be waived." c)         A section entitled "Section 1: Applicant Information", which will request the following information: 1)         Full name; 2)         Date of birth; 3)         Applicant's role in child's care; 4)         Background check purpose; 5)         Background check type; 6)         Case number; and 7)         Date submitted. d)         A section entitled "Section 2: Evaluation Criteria", which includes the following guidelines for reviewing the criminal history.  Even if the background check results reveal a criminal conviction for the relative caregiver applicant or any other person living in the home, the agency may approve them so long as there is proof that the conviction will not affect the child's safety and well-being. The agency may consider the following factors: 1)         The type of crime; 2)         The amount of time that has passed since the crime; 3)         The individual's age at the time of conviction; 4)         The seriousness of the crime; 5)         Evidence of rehabilitation since conviction (may include completion of treatment, court-ordered classes, community service, character references, etc.); 6)         The total number and type of crimes, and ages at the time they were committed; and 7)         The role the individual plans to have with the child. e)         A section entitled "Section 3: Background Information", which requests the following information: 1)         Criminal conviction; 2)         Date of the conviction; and 3)         A description of what happened, where, and who was involved. f)         A section entitled "Section 4: Additional Background Information", which requests the following information: 1)         Child abuse and neglect history; 2)         Child's age and any special needs; 3)         Evidence of changed behavior; 4)         Who completed the form; 5)         Title of the person who completed the form; and 6)         The date the form was completed. g)         A section entitled "Section 5: Decision", which is to be completed by a supervisor or higher, to select whether the individual passed, passed for certification purposes only, or did not pass the criminal history evaluation with a place for comments in support of the decision. The decision also includes a place for the name, title, and the date of the person who made the decision.