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Free Louisiana Central Registry Form

The Louisiana Central Registry Disclosure Form is a document required by the Louisiana Department of Children and Family Services for individuals involved with licensed child care or juvenile detention facilities. This form collects essential personal information and ensures that all owners, operators, administrators, employees, and volunteers are not listed as perpetrators of child abuse or neglect. Completing this form accurately is crucial, as any false information can lead to serious legal consequences.

To ensure compliance and protect the well-being of children, fill out the form by clicking the button below.

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Structure

The Louisiana Central Registry Disclosure Form is a crucial document for anyone involved in child care or juvenile detention facilities licensed by the Louisiana Department of Children and Family Services. This form must be filled out by owners, operators, administrators, current or prospective employees, and volunteers. It serves to ensure that individuals working in these sensitive environments have been thoroughly vetted. Notably, the form requires personal information, including the individual’s name, date of birth, and social security number. It also asks about any previous names used and requires disclosure of any justified findings of child abuse or neglect. Falsifying information on this form is a serious offense, carrying potential fines or imprisonment. Once completed, the form must be kept on file by the facility owner or operator, adhering to the state's licensing standards. This process helps maintain a safe environment for children and reinforces accountability within child care services.

Sample - Louisiana Central Registry Form

SCR-1 LIC

Rev. 01/13

06/11 Issue Obsolete

STATE OF LOUISIANA

DEPARTMENT OF CHILDREN AND FAMILY SERVICES STATE CENTRAL REGISTRY DISCLOSURE FORM

This form must be completed by each individual owner, operator, administrator, current or prospective employee or volunteer of a child care facility or juvenile detention facility licensed by the Louisiana Department of Children and Family Services for themselves. Any owner, operator, administrator, current or prospective employee, or volunteer of a child care facility or juvenile detention facility licensed by the department who knowingly falsifies the information on the State Central Registry Disclosure Form shall be guilty of a misdemeanor offense and shall be fined not more than five hundred dollars, or imprisoned for not more than six months, or both. R.S. 46:1414.1.C or R.S. 15:1110.2(C).

This form shall be maintained by the owner/operator of the licensed facility in accordance with current licensing standards as mandated by R.S. 46:1414.1.B or R.S. 15:1110.2(B).

Name of Licensed Facility (Print or Type)

Physical Address of Licensed Facility

License #

Name of Individual/Applicant (Print or Type)

Date of Birth

Social Security #

Maiden, Previous or Any Other Name Used

Race

Sex

Current Street Address

City and State

Zip Code

Most Recent Previous Address

City and State

Zip Code

(

)

(

)

(

)

Current Home Phone #

Current Cell Phone #

Work Phone #

My name

is not

currently recorded as a perpetrator on the State Central Registry for what the

(check one)

Department of Children and Family Services (DCFS) has determined to be a justified

(valid) finding of child abuse or neglect.

have

have not

been determined to have a justified (valid) finding of abuse or neglect since the Risk

Evaluation Panel finding.

If the DCFS Licensing Section has reasonable suspicion or is provided with facts or information that your name is on the State Central Registry as a perpetrator with a valid/justified finding of abuse and/or neglect, the Licensing Section may request a clearance of the SCR without your permission. If your name does in fact appear on the SCR as described above, the department will notify both your employer (the facility named above) and the appropriate District Attorney’s office of your failure to comply with R.S. 46:1414.1 or R.S. 15:1110.2.

The information given is true and complete to the best of my knowledge.

Signature		Date

Signature of Licensed Facility Representative		Date

↓ Louisiana Central Registry File

Form Characteristics

Fact Name	Details
Purpose	The Louisiana Central Registry Disclosure Form is required for individuals involved with licensed child care or juvenile detention facilities.
Who Must Complete	All owners, operators, administrators, employees, and volunteers must complete this form.
Falsification Penalty	Falsifying information on the form is a misdemeanor, punishable by a fine up to $500 or up to six months in prison.
Governing Laws	The form is governed by R.S. 46:1414.1.C and R.S. 15:1110.2(C).
Record Maintenance	The licensed facility must maintain this form according to licensing standards set by R.S. 46:1414.1.B and R.S. 15:1110.2(B).
Information Required	The form requires personal information, including name, date of birth, social security number, and current addresses.
Abuse Finding Disclosure	Individuals must disclose if they have been found to have a justified finding of abuse or neglect.
Department Authority	The Department of Children and Family Services can request a clearance of the SCR without the individual's permission if there is reasonable suspicion.
Notification Requirement	If an individual is found on the SCR, the department will notify the employer and the District Attorney’s office.

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