Department of Family and Children S Services

Santa Clara County Social Services Agency Department of Family and Children’s Services

SHERIFF’S DEPARTMENT CRIMINAL RECORD CHECK REQUEST (CLETS)

REQUEST PRIORITY: PLEASE PRINT, TYPE OR WORD-PROCESS ENTRIES. Received Urgent (same or next day results) Regular (2 day results) Initial Request Update Request Date Time From: Social Worker Requesting CLETS To: Receiving, Assessment & Intake Center Name: SW #: Email: [email protected] Phone #: W. Julian Floor #: Phone: (408) 792-1860 From: Receiving, Assessment & Intake Center To: Sheriff’s Dept., Records From: Sheriff’s Department, Records To: Receiving, Assessment & Intake Center . DFCS Case Name: SSA Case Number:

Subject’s Name: Jr. Sr. Last First Middle AKA’s: Date of Birth: Female Male Driver’s Lic. No.: Soc. Sec No. FBI No. CII No. PFN No.: Last Known Address: Number - Street - Apt. City State Zip Purpose of Record Check: Legal Basis for Access to CLETS: Welfare and Institutions Code §§ 272, 308, 309, 319, 328, 361.4, WIC 388(e)(4), and 16504.5 To conduct an investigation pursuant to Section 11166.3 of the Penal Code or an investigation involving a child in which the child is alleged to come within the jurisdiction of the juvenile court under Section 300. Subject’s Relationship to Child: Parent Guardian Other: To document that a parent and other adult under investigation or assessment was put on notice of the requirement to submit to fingerprinting, the person refused to submit to fingerprinting or the whereabouts of the person is unknown, use the SCZ 152A. To assess the appropriateness and safety of placing a child who has been detained or is a dependent of the court, in the approved home of a relative pursuant to Section 309 or 361.4, or the approved home of a non-relative extended family member as described in Section 362.7. Subject’s Relationship to Child: Relative Caregiver Non-Relative Extended Family Member Caregiver (NREFM) OR Another person involved with the relative’s or NREFM’s home: Another adult in the home A person age 18 years or older who has significant contact with the child (other than a professional providing the child a service), including any person who has a familial or intimate relationship with any person living in home A child over the age of 14 years in the home who is believed to have a criminal record An adult providing temporary care for a child placed in the home. To document that a relative or NREFM caregiver or other adults involved with the relative’s or NREFM’s home was put on notice of the requirement to submit to fingerprinting, use the SCZ 152. To attempt to locate a parent or guardian pursuant to Section 311 of a child who is the subject of dependency court proceedings. To determine appropriate placement options for a non-minor prior to placing the non-minor in a setting with minor dependents. CLETS CHECKS FOR RELATIVE AND NREFM CAREGIVERS AND ADULTS ASSOCIATED WITH THEIR HOMES WHO HAVE FREQUENT CONTACT WITH THE CHILD(REN) MUST BE FOLLOWED BY LIVE SCAN FINGERPRINTING WITHIN 10 JUDICIAL DAYS OF DATE OF THE SHERIFF’S DEPARTMENT CLETS RESPONSE (SEE DATE OF SHERIFF’S DEPARTMENT STAFF PERSON’S SIGNATURE BELOW). I hereby certify that the above information is true to the best of my knowledge. The requestor certifies that CLETS information will not be released to any unauthorized person. Name of Requestor (print): Worker No.: Signature of Requestor: Phone No.:

No Criminal Record Found Subject has a Warrant? Yes No Update (subsequent request) for this same individual: Please see original criminal record check results sent to: No New Criminal Record Found New Criminal Record Found and New Record (only) ______on ______

Signature of Sheriff’s Department Records Division Staff Person Date

SCZ 686A.doc Filing: 4th Fastener, Right - Under Sheriff’s Department Criminal Record Check Request (CLETS) – Rev. 5/1/13 Page 1 of 1 Santa Clara County Social Services Agency Department of Family and Children’s Services LIVE SCAN REFERRAL USE THIS FORM FOR CAREGIVERS, ADDITIONAL ADULTS IN THEIR HOMES OR ADULTS ASSOCIATED WITH A RELATIVE’S OR NREFM’S HOME, AND OFFICIAL VOLUNTEERS.

Referral Date: USE ONE FORM FOR EACH INDIVIDUAL. The Social Worker must check this box, if applicable: Because you are a person in or associated with a relative or NREFM home, fingerprinting must be done by (date), which is 10 days from the date of the CLETS record check. If you are not fingerprinted by this date, the Social Worker will conclude that you refuse to be fingerprinted. Case Information Check appropriate box(s) next to “Name” in this section. For relatives and NREFMs, enter child(ren)’s name(s) and DFCS case number. For adoptive home and foster care license applicants, enter name(s) of applicant(s). For volunteers, enter volunteer’s name.

Name Child License Applicant Adoption Home Study Applicant NMD Volunteer DFCS Case Number Information about Person to be Fingerprinted

Full Name (last, first, middle) Date of Birth Place of Birth

Other Names Used (e.g., maiden name, alias) Driver’s License No. Social Security No.

Residence Street Address City State Zip Code Citizenship: U.S. Citizen? Yes No If not, citizen of what country?

Reason for Criminal and/or Child Abuse Record Check Select the “Reason for Record Check” and place an “x” in the box in that row indicating if the person is a primary applicant* or an additional adult.** Primary Addition Return Reason for Record Check Appli al Adult Responses to: cant SubArrest Relative (For assessment of prospective relative and Undersigned DFCS non-relative extended family members [NREFM] for approval) Social Worker Resource Homes Foster Home License (For foster home license applicants) Unit Supervisor Designated Petition for Adoption (For adoption home study applicants) Resource Homes Unit Supervisor Undersigned DFCS Placement options for a non-minor dependent (NMD) Staff Person Undersigned DFCS Volunteer participating in an Official Volunteer Programs N/A Staff Person *A “Primary Applicant” is a prospective relative or NREFM caregiver; an applicant for a foster care license and/or an adoptive home study; or a prospective DFCS volunteer. **An “Additional Adult” is a person age 18 years or older residing in the home of an applicant; a person age 18 years or older residing outside the caregiver’s home (other than a professional providing services to the child) known to the social worker to have significant contact with the child, including any person who has a familial or intimate relationship with any person living in the home; any person over the age of 14 years living in the home who the social worker believes may have a criminal record; or respite care provider. NOTE: An applicant for a foster care license or relative/NREFM approval and an adoption home study (an “adoptive concurrent placement” applicant) must be fingerprinted twice: once for each type of caregiver assessments.

Referred by: ( ) DFCS Staff Person’s Name (Please Print) Worker Number Telephone Number

SCZ152 Filing: 4th Fastener, Right - Under Live Scan Request – Rev. 4/29/14 SP  Page 1 of 2 Santa Clara County Social Services Agency Department of Family and Children’s Services

INFORMACIÓN SOBRE OFICINAS Y PROCEDIMIENTOS DE HUELLAS DIGITALES DE LIVE SCAN Los PASOS para tomarse las huellas digitales por Live Scan depende dónde se las quiera tomar. Sus opciones son: Oficinas del Departamento de Servicios para Familias y Niños (DFCS) Oficina Principal de DFCS Receiving, Assessment and Intake Center 373 W. Julian Street, Primer piso 725 E. Santa Clara St., Suite 100 (Primer piso) San José, CA 95110 San José, CA 95112 Para citas llame al (408) 501-6302 Llame para ver si hay citas disponibles al (408) 792-1860 Citas:  Lunes, miércoles, jueves y viernes. – 8:30 a.m. a 4:30 p.m.  Martes – 8:30 a.m. a 6:30 p.m. Oficinas del Departamento del Alguacil del Condado de Santa Clara Oficina Central Subestación de West Valley 55 West Younger Ave. 1601 South De Anza Blvd. San José, CA 95110 Cupertino, CA 95014 Para citas llame al (408) 808-4760 Para citas llame al (408) 868-6614 Solamente por cita- No le atenderemos sin cita: Citas: (Solicitantes sin cita hasta las 2:30pm – depende de  Lunes a viernes - 7:00 a.m. a 4:30 p.m. disponibilidad)  Lunes a viernes. - 8:30 a.m. a 4:30 p.m. (Cerrado de 12:00 a 1:00 p.m.) Subestación del Condado del Sur Subestación de Stanford 80 Highland Avenue, Bldg. K 711 Sierra St. San Martín, CA 95046 Stanford, CA 94305 Para citas llame al (408) 686-3651 Para citas llame al (650) 725-2499 Solamente por cita – No le atenderemos sin cita: Citas:  Lunes a viernes - 7:30 a.m. a 4:00 p.m.  Lunes a viernes – 7:30 a.m. a 4:00 p.m. (Cerrado de 12:00 a 1:00 p.m.) Oficinas del Departamento del Alguacil en Otros Condados de California Contacte al Departamento del Alguacil en el condado de California donde quiera tomarse las huellas digitales para saber dónde quedan las oficinas.

PASOS para Oficinas del Departamento de Servicios para Familias y Niños (DFCS): 1. Llame para hacer una cita para tomarse las huellas digitales en la oficina más conveniente para usted. 2. Llegue por lo menos 30 minutos antes de la cita. 3. Traiga una tarjeta de identidad con foto emitida por el gobierno o un documento a la cita.* 4. Presente esta forma “Live Scan Referral” al personal de DFCS.

PASOS para Oficinas del Departamento del Alguacil del Condado de Santa Clara: 1. Llame a una de las siguientes oficinas de DFCS para obtener la forma “Request for Live Scan Services”: Oficinas de DFCS en San José Oficinas del Sur del Condado Receiving Assessment & (408) 792- Intake Center 1860 Gilroy Family Center (408) 758-3440 (408) 501- South County Child Welfare Calle West Julian 6302 Office (408) 758-3440

2. Traiga una tarjeta de identidad con foto emitida por el gobierno o un documento a la cita.* 3. Presente esta forma “Live Scan Referral” y la forma “Request for Live Scan Services” al personal del Departamento del Alguacil. Nota: Si usted elige ir a la oficina en la 55 West Younger, regístrese en la ventanilla del Agente ubicada en la parte izquierda de la sala, cerca a los teléfonos públicos. No agarre un número ni espere en la fila.

PASOS para Oficinas del Departamento del Alguacil en Otros Condados de California: 1. Llame al (408) 501-6337 (la oficina principal de DFCS en San José) para obtener la forma “Request for Live Scan Services.” 2. Cuando recibe la forma “Request for Live Scan Services,” favor de llamar al Departamento del Sheriff inmediatamente y siga los procedimientos de ese departamento para personas que quieran tomarse huellas digitales con Live Scan. 3. Traiga una tarjeta de identidad con foto emitida por el gobierno o un documento a la cita.* 4. Presente esta forma “Live Scan Referral” y la forma “Request for Live Scan Services” al personal del Departamento del Alguacil. *Identificación con foto: Tiene que presentar una tarjeta de identidad con foto emitida por el gobierno o documento (p.ej., tarjeta del Departamento de Vehículos Motorizados (DMV) de California, licencia de conducir, pasaporte, documentación del consulado de otro condado). Las tarjetas de crédito no se pueden usar como prueba de identidad. Información adicional

SCZ152 Filing: 4th Fastener, Right - Under Live Scan Request – Rev. 4/29/14 SP  Page 2 of 2 Santa Clara County Social Services Agency Department of Family and Children’s Services

 Favor de llegar a tiempo a la cita y de llamar si ya no puede llegar. Puede que las personas que lleguen tarde tengan que llamar para reprogramar la cita. Las citas para huellas digitales pueden ser reprogramadas.  Uñas demasiado largas o curvas obstaculizarán la toma de huellas digitales.  Cortaduras o heridas en la punta de los dedos obstaculizarán la toma de huellas digitales. Programe la cita de huellas digitales de Live Scan después que haya sanado la herida. Notifique al trabajador social que la cita para tomarse las huellas digitales se demoró.  Usted no podrá supervisar a niños durante la cita para tomarse las huellas digitales. Si trae a niños, favor de hacer arreglos para cuidado infantil.

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