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Effective Date: 




Updated: 1/2019



A person interested in being associated with operations regulated by Child Care Licensing (CCL) must use this form to submit a risk evaluation for himself or herself if that person:

  • has criminal history or Central Registry (or out-of-state abuse/neglect) history that is a violation of minimum standards that is eligible for a risk evaluation; and
  • is pursuing an association (including employment or volunteering) with a child care operation or home regulated by CCL.


To complete this form, fill in all fields with the appropriate information.

Send the completed form and the additional required documents (from the checklist on the form) to your CCL Centralized Background Check Unit (CBCU) representative via mail, email or fax by the due date provided in the Background Check Results Requiring Action letter. The name, mailing address, email address and fax number of the CBCU representative are listed at the bottom of the Background Check Results Requiring Action letter. Keep a copy of this form and the attachments for your files.

Once CBCU receives and processes all required documentation, CBCU will send you a letter notifying you whether or not the risk evaluation was approved. An approved or conditionally approved risk evaluation is specific to a particular role.

Note: If you have an approved or conditionally approved risk evaluation and your role at the operation changes, the risk evaluation is no longer valid. A new risk evaluation must be submitted and approved.

If CBCU denies the risk evaluation, you are not eligible to work at or with the operation, effective immediately upon receipt of the risk evaluation determination letter.