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Out of State Registry Check Instructions/Forms

The overall background check process includes a check of any applicable out of state registries if the applicant has lived in another state during the last (5) years.  Please see the instructions for completing the out of state registry check portion of the background check process below.

If an applicant for child care employment has lived in another state during the last five (5) years select the state(s) from the dropdown box and follow the instructions for each state in which the individual has lived.  Submit the forms as instructed along with any required documentation.  Each form may have different requirements.  Most forms require a signature.  Others may require a witness, original signatures, notarization, and some require a copy of the applicant's photo identification. 

Please read the instructions carefully.   States may return forms unprocessed if information is missing or unreadable.

Commonly Used Acronyms

CAN = Child Abuse and Neglect Registry
N/A = Not Applicable
SDF = Supplemental Disclosure Form
TBD = To Be Determined
VPR = Vulnerable Persons Registry (or equivalent)

In addition to any required forms for other states, each applicant must submit a Supplemental Disclosure Form (SDF) to the Department of Human Services (DHS).  ONLY SUBMIT AN SDF FORM IF THE APPLICANT HAS LIVED IN ANOTHER STATE DURING THE LAST FIVE YEARS.  Print the information clearly to ensure that it is legible. 

Supplemental Disclosure Form (SDF)

RETURN ANY REQUIRED FORMS to DHS via the options listed below.

IMPORTANT NOTE: ONLY SEND FORMS WITH PERSONALLY
IDENTIFIABLE INFORMATION USING A SECURE METHOD.

SECURE FORMS PORTAL:  Send any forms with Personally Identifiable Information, such as Social Security numbers, to DHS via the secure forms portal.  Click on the link, upload the form, and send it to DHS.

Secure Forms Portal

FAX:  615-532-9956 This is a dedicated fax that goes directly to the registry check processing unit.

MAILING ADDRESS:   Tennessee Department of Human Services, Attn: Child and Adult Care Licensing, Citizens Plaza Building, 8th Fl., 400 Deaderick Street, Nashville, TN 37243-1403

EMAIL:  Use the mailbox below for general communications about the background check process.  DO NOT USE THE MAILBOX TO SEND PERSONALLY IDENTIFIABLE INFORMATION UNLESS YOU HAVE THE ABILITY TO SEND SECURE EMAIL.

CCBackground.DHS@tn.gov

 

Additional Information

As the volume of registry check requests to other states increases, other states may change their process/forms to better accommodate those requests.  Therefore, we will update this information as needed to reflect any changes in the process.

If you require additional information about the background check process, you can contact us via the dedicated phone line at:   (615) 253-4170.

 

ALABAMA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.
The completed Alabama 1598 must be mailed to DHS because they require us to submit the original form with original signatures.

CAN Registry Form:
Alabama Form 1598

ALASKA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.

CAN Registry Form:
Alaska Form 06-9437

ARIZONA

VPR Registry Instructions:
There is no form for the applicant to complete.  DHS reviews the list online.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with SDF.  Note the fields that are marked as not applicable for this purpose.

CAN Registry Form: 
Arizona Form DCS-1083A     

ARKANSAS

VPR Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with SDF.  Note that the form must be notarized. 

VPR Registry Form:
Arkansas Form APS-0001

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.  Note that the form must be notarized.

Do not submit a fee.  Any required registry check fees are paid by DHS. 

CAN Registry Form:
Arkansas CAN Request Form

CALIFORNIA

VPR Registry Instructions:
DHS will search the registry through the online portal.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

COLORADO

VPR Registry Instructions:
DHS will search the registry through the online portal.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.  Note that the form requires two signatures.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Colorado Form for Individual Request

CONNECTICUT

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF. 

CAN Registry Form:
Connecticut Form DCF 3031

DELAWARE

VPR Registry Instructions:
DHS will search the registry through the online portal.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.

CAN Registry Form:
Delaware Child Protection Registry Request Form

FLORIDA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific information, signs the form and returns it to DHS along with the SDF.
Do not send the form directly to Florida, because DHS must also sign the form. 

CAN Registry Form:
FL Form 1651a

GEORGIA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form:
DHS completes and submits form (no applicant signature required).

HAWAII

VPR Registry Instructions:  TBD

VPR Registry Form: TBD

CAN Registry Instructions:
Applicant completes the form and returns it to DHS along with the SDF.  Note that the completed form must be mailed to DHS because the original is required for submission.

CAN Registry Form:
Hawaii Consent Form

IDAHO

VPR Registry Instructions:  NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.
Note that the form must be notarized. 

CAN Registry Form:
Idaho CP Registry Form

ILLINOIS

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific portion of the form and returns it to DHS along with the SDF.

CAN Registry Form:
Illinois Form CFS 689

INDIANA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes Item 1 in Section A and all of Section B and returns the form to DHS along with the SDF.

CAN Registry Form:
Indiana Form 52802

IOWA

VPR Registry Instructions:
No Separate form - same form as child abuse and neglect form.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific information in Section 1, signs the form in Section 2 and returns it to DHS along with the SDF.

CAN Registry Form:
Iowa Form 470-3301

KANSAS

VPR Registry Instructions:
Applicant completes the applicant specific information, signs the form and returns it to DHS along with SDF.

VPR Registry Form:
Kansas Form PPS 10400

CAN Registry Instructions:
Applicant completes the applicant specific information, signs the form and returns it to DHS along with the SDF.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Kansas Form PPS1011

KENTUCKY

VPR Registry Instructions:
Kentucky Adult Caregiver Misconduct Registry - Online check is completed by DHS.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the applicant specific information, signs the form and returns it to DHS along with SDF.  Note that the form requires a witness.  The applicant must also submit identifying information such as a copy of their driver's license, social security card, or birth certificate.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Kentucky Form DPP 156

LOUISIANA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

MAINE

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions: TBD

CAN Registry Form: TBD

MARYLAND

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes information in Sections II, III, IV, and V and returns to DHS along with SDF.

CAN Registry Form:
Maryland Form SSA 1279A

MASSACHUSETTS

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

MICHIGAN

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes Section 1 and returns to DHS along with a copy of SDF.  Note that you must include a copy of your photo ID.

CAN Registry Form:
Michigan Form DHS-1929

MINNESOTA

VPR Registry Instructions:
No separate form - same form as child abuse and neglect form.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Minnesota Consent Form

MISSISSIPPI

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information, signs the form and returns it to DHS along with SDF.  Note that witness is required.

CAN Registry Form:
Mississippi CAN Form

MISSOURI

VPR Registry Instructions:
No separate form – see CAN registry information.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes Block II and returns it to DHS along with SDF.  Form must be notarized.

CAN Registry Form:
Missouri Form 300-1590s

MONTANA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF.  Form must be notarized.

CAN Registry Form:
Montana Form CFS 400

NEBRASKA

VPR Registry Instructions:
One form used for both registries - See Child Abuse Registry information.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF.  Form must be notarized. 

CAN Registry Form:
Nebraska Registry Form

NEVADA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF and a copy of photo ID.

CAN Registry Form:
Nevada Registry Form

NEW HAMPSHIRE

VPR Registry Instructions:  NA
 

VPR Registry Form:  NA
 

CAN Registry Instructions:
Applicant completes and submits the form to NH and sends a copy of the submitted form to DHS along with the SDF.  Note that the form must be notarized and a Self-Addressed Stamped Envelope (SASE) is required.  Once the applicant receives the results of the registry check they must send a copy to DHS.

CAN Registry Form:
New Hampshire Form 2202

NEW JERSEY

VPR Registry Instructions:  TBD

VPR Registry Form:  TBD

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF. 

CAN Registry Form:
New Jersey CARI Form

NEW MEXICO

VPR Registry Instructions:
Information submitted by DHS. 

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information, signs the form, and returns it to DHS along with SDF.

CAN Registry Form:
New Mexico CAN Form

NEW YORK

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF.  Form must be notarized.
Note:  Since the original form is required it must be mailed to DHS.

CAN Registry Form:
New York Authorization Form

NORTH CAROLINA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information, signs the form, and returns it to DHS along with SDF.

CAN Registry Form:
North Carolina Form DSS 5268

NORTH DAKOTA

VPR Registry Instructions:
Information submitted by DHS.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information, signs the form, and returns it to DHS along with SDF.

CAN Registry Form:
North Dakota Form SFN 433

OHIO

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Ohio law does not allow release of information to another state agency for employment purposes.  Applicant must submit search request directly to OH and send us a copy of the form that was submitted along with the SDF.  Once the applicant receives the results of the self-screening they must send a copy to DHS. 

CAN Registry Form:
Ohio SACWIS Form

OKLAHOMA

VPR Registry Instructions:
Online registry is checked by DHS.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

OREGON

VPR Registry Instructions: TBD

VPR Registry Form: TBD

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

PENNSYLVANIA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes the consent release form and PA CY113 and returns them along with the SDF to DHS.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
PA Consent Release Form
PA CY113

RHODE ISLAND

VPR Registry Instructions: TBD

VPR Registry Form: TBD

CAN Registry Instructions:
Applicant sends SDF to DHS.

CAN Registry Form: NA

SOUTH CAROLINA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information in section IV, signs the form in section V, and returns it to DHS along with SDF.
Note that the form must be witnessed or notarized.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
South Carolina Form DSS 3072

SOUTH DAKOTA

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes and submits self- screening form to SD and sends a copy of the submitted form to DHS along with SDF.  Note that the form must be notarized.  The applicant should include their email address at the bottom of the form if they want the results emailed to them. Once the applicant receives the results of the self-screening they must send a copy to DHS. 

CAN Registry Form:
South Dakota Self-Screening Form

TEXAS

VPR Registry Instructions:
DHS completes the check through online portal.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information, has the form notarized, and returns it to DHS along with SDF. Note that a copy of a photo ID is required.

CAN Registry Form:
Texas Form 500-2970 (Updated)

UTAH

VPR Registry Instructions:
DHS completes the check through online portal.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns the completed form to DHS along with SDF.  Note that a copy of a photo ID is required.

CAN Registry Form:
Utah Informed Consent Form

VERMONT

VPR Registry Instructions: TBD

VPR Registry Form: TBD

CAN Registry Instructions:
Applicant completes applicant specific information and returns it to DHS along with SDF.  Note that the form must be notarized, it must be mailed via USPS mail, and a Self Addressed Stamped Envelope (SASE) is required.  DHS will provide the SASE when they submit the form. 

CAN Registry Form:
Vermont Self-Check Form

VIRGINIA 

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns the form to DHS along with SDF.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Virginia Form 032—02-0151-12

WASHINGTON

VPR Registry Instructions: NA

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns the form to DHS along with SDF.

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Washington Form 23-041

WASHINGTON DC

VPR Registry Instructions:  TBD

VPR Registry Form:  TBD

CAN Registry Instructions:
Applicant completes the form and returns it to DHS along with the SDF.  The completed form must be mailed to DHS because the original is required for submissions.  Note that the form must be notarized.

CAN Registry Form:
DC Child Protection Registry Check 

WEST VIRGINIA

VPR Registry Instructions:
One form used for both registries - See Child Abuse Registry information.

VPR Registry Form:
See CAN registry form.

CAN Registry Instructions:
Applicant completes applicant specific information and returns the form to DHS along with SDF.  Note that the original form is required.  Therefore, the form must be mailed to DHS.

CAN Registry Form:
West Virginia Authorization Release

WISCONSIN

VPR Registry Instructions:
DHS reviews the registry online.

VPR Registry Form: NA

CAN Registry Instructions:
Applicant completes applicant specific information and returns the form to DHS along with SDF.

CAN Registry Form:
Wisconsin Form 5065

WYOMING

VPR Registry Instructions:
One form used for both registries - See CAN Registry information.

VPR Registry Form:
See CAN registry form.

CAN Registry Instructions:
Applicant completes the applicant specific information and returns the form to DHS along with SDF.  Note you must mail the completed form to DHS because original signatures are required.  DHS will submit the form with the required Self Addressed Stamped Envelope (SASE) .

Do not submit a fee.  Any required registry check fees are paid by DHS.

CAN Registry Form:
Wyoming Form SS-26