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Effective Date: 
2/2016

Documents

Instructions

Updated: 2/2016

Purpose

Form 2357 is completed by an Adult Foster Care (AFC) applicant and each identified substitute. The assigned Community Services Contracts (CSC) contract specialist sends the completed form to the Department of Family and Protective Services (DFPS) to determine if the applicant or any substitute has been identified as a perpetrator in a validated Adult Protective Services (APS) case.

Procedure

When to Prepare

The form is part of the application packet for an individual who is requesting to have an AFC contract. The applicant and each substitute will complete Form 2357. All information requested at the top portion of the form must be completed to conduct an accurate records check. The applicant must sign and date the form.

Transmittal

Email extaccbgc@dfps.state.tx.us OR mail the original Form 2357 and a self-addressed envelope with the CSC contract specialist’s address to the Centralized Background Check Unit (CBCU) for DFPS at the following address:

DFPS — CBCU Non-Licensing Unit
Mail Code 1217
P.O. Box 149030
Austin, TX 78714

Form Retention

HHSC will use the information from Form 2357 to determine if the applicant can be approved as an AFC provider and if the substitutes can be approved. If the applicant is approved as a provider, HHSC maintains the completed Form 2357 during the period the applicant serves as a provider. Form 2357 must be submitted for review for any new substitutes to provider rules.

The CBCU does not maintain a copy of Form 2357 after conducting the data base search. The local APS office does not maintain a copy following due process.

DETAILED INSTRUCTIONS

Name of Applicant or Substitute — Enter the applicant’s or substitutes's last name, first name and middle name.

Race — Self-explanatory.

Other Names Applicant May Have Gone By — Enter the maiden name, alias, etc.

Current Address — Enter the street, city, state and ZIP code.

County — Enter the name of the county.

Previous Address Used — Enter the previous street, city, state and ZIP code.

County — Enter the name of the county.

Area Code and Telephone No.— Enter the area code and telephone number.

Date of Birth— Enter the applicant's date of birth.

Gender— Check the box for Male or Female.

Social Security No.— Enter the applicant's Social Security number.

Signature — Applicant, Date— The applicant must sign and date the form.

To Be Completed by DFPS— A designated CBCU staff conducts the records check to determine if there is a possible match. The DFPS staff completing the form checks the appropriate box for "No Match" or "Match."

Type of Maltreatment— The DFPS staff checks the boxes for all types of maltreatment that apply and enters the date the incident occurred.

Relationship of Perpetrator to Victim— The DFPS staff checks the appropriate box and enters the Case ID number.

Give a brief description of the incident— The DFPS staff briefly describes the incident.

Describe APS intervention (if any)— The DFPS staff briefly describes the intervention if one occurred.

Signature — Person Completing Form, Date— The DFPS staff signs the form and enters the date.

Title of Person Completing Form— The DFPS staff enters his/her job title.

Please Return To: HHSC Community Services Contract Specialist, Email Address, Area Code and Telephone No., and Mail Code — Enter the name of the HHSC CSC contract specialist, email address, area code and telephone number, and mail code.

Note: If a match is not found, the completed Form 2357 for the applicant and the substitute is returned to the CSC contract specialist for continued processing for the applicant.

If CBCU staff determine that a match is found, CBCU staff will send Form 2357 to the local APS office where APS will take the appropriate steps regarding an administrative review and a release hearing. Due process must be completed prior to the transmittal of any information to the CSC contract specialist.

If a possible match is found, CBCU staff will also send Form 2357 to APS state office for further review. If APS state office determines there is a match, the regional office will be notified in order to provide due process to the applicant before releasing the findings to the CSC contract specialist.

If the additional information provided does not result in a match, APS state office will complete Form 2357 and send it to the APS caseworker, who will then forward to the HHSC CSC contract specialist.

Notes:

  • If the finding was upheld, APS may release information regarding the maltreatment. If necessary, the APS staff completing Form 2357 may write "See Attached" in the space designated for a description of the incident. A detailed explanation of the incident may then be documented on agency letterhead.
  • If the finding was overturned, Form 2357 is completed by the local APS office as though there was not a match.