Iowa Department of Human Services


Iowa Department of Human Services

Authorization for Release of Child and Dependent Adult Abuse Information

This form must be used to authorize the release of child or dependent adult abuse information when the person requesting the information does not have independent access to it under Iowa law. Complete a separate form for each person for whom information is requested and email to dhsabusereqistry@dhs state ia us, or fax to (515) 564-4112, or mail to the Iowa Department of Human Services, Central Abuse Registry, P.O. Box 4826, Des Moines, IA 503055.

Please specify which abuse registry you are requesting by checking the appropriate box below: 

 

Please specify your preferred method of response by checking a box and completing the information in Section 1.

Address: Fax: Email:

Section 1: To be completed by the person or agency requesting the information.

Requester: Last, First               Agency Name

West, Corinne                           Sapphire Background Check

Telephone Number ( 718 ) 704-0040

Address

117 Ditmas Avenue

Fax Number

( 718 ) 228-7189

City Brooklyn

State NY

Zip Code 11215

Email cs@sapphirecheck.com

List the name and address of the person whose information is being requested

Name: (last, first, middle)

Birth Date:

Social Security Number:

Address:

City

Country:

State:

List maiden name, previous married names, and any alias:

What is the purpose of your request for child or dependent adult abuse information?

Pre-Employment

I have read and understand the legal provisions for handling child and dependent adult abuse information which is printed on the second page of this form.

Signature of Requestor                                                                                Date

Section 2:To be completed by the person authorizing the Department of Human Services to release their

child or dependent adult abuse information.

I understand that my signature authorizes the requester to receive information to verify whether I am named on the Child Abuse or Dependent Adult Abuse Registry as having abused a child (Iowa Code section 235A.15) or dependent adult (Iowa Code section 235B.6). To the best of my knowledge, the information contained in Section 1 of this form is correct.

Signature of person Authorizing                                                                   Date

Section 3: To be completed by the Central Abuse Registry or designee.

 

Signature of Registry Staff or Designee                                                                   Date

Comments:

           

 

LEGAL PROVISIONS FOR HANDLING

CHILD AND DEPENDENT ADULT ABUSE INFORMATION

 

Redissemination of Child and Dependent Adult Abuse Information

(Iowa Code sections 235A.17 and 235B.8)

A person, agency, or other recipient of child or dependent adult abuse information shall not redisseminate (release) this information, except that redissemination is permitted when ALL of the following conditions apply:

Criminal Penalties (Iowa Code sections 235A.21 and 235B.12)

A person is guilty of a criminal offense when the person:

Upon conviction for each offense, the person is guilty of a serious misdemeanor punishable by a fine or imprisonment.

Any person who knowingly, but without criminal purposes, communicates or seeks to communicate child or dependent adult abuse information except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8 is guilty of a simple misdemeanor punishable, upon conviction for each offense, by a fine or imprisonment.

Any reasonable grounds for belief that a person has violated any provision of Iowa Code Chapters 235A or 235B shall be grounds for the immediate withdrawal of any authorized access that person might otherwise have to the child or dependent adult abuse information.

Signature of Registry Staff or Designee                                                                                 Date

Leave this empty:

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Signature Certificate
Document name: Iowa Department of Human Services
lock iconUnique Document ID: 3e1562d35feaed966e38e7a0fe60b36e494380e0
Timestamp Audit
August 11, 2021 7:33 am EDTIowa Department of Human Services Uploaded by Sapphire check - support@sapphirecheck.com IP 106.196.103.105