Texas Department of Aging and Disability Services

Form 2357 July 2011

DFPS Records Check

Name of Applicant (Last, First, Middle) Nombre del solicitante (apellido, primer nombre, segundo nombre) Other Names Applicant May Have Gone By (Maiden, Alias) Otros nombres que el solicitante quizs haya usado (nombre de soltera, alias) Current Address (Street, City, State, ZIP)/Direccin actual (calle, ciudad, estado, cdigo postal) Previous Address Used (Street, City, State, ZIP)/Direccin previa (calle, ciudad, estado, cdigo postal) Area Code and Telephone No./ Telfono con clave del rea Date of Birth/ Fecha de nacimiento County/Condado County/Condado Social Security No./Nm. de Seguro Social Race/Raza

Gender/Sexo Male/Masculino Female/Femenino

I understand that my name will be submitted to the Texas Department of Family and Protective Services (DFPS), to determine whether I have been named a validated perpetrator of abuse, neglect or exploitation against an elderly or disabled individual. I understand that my status as a validated perpetrator could prevent me from contracting as a DADS adult foster care provider.

Entiendo que mi nombre ser enviado al Departamento de Servicios para la Familia y de Proteccin (DFPS) de Texas, para establecer si he sido nombrado en una denuncia vlida como autor de abuso, maltrato, descuido o explotacin de un adulto mayor o una persona discapacitada. Entiendo que es posible que el DADS no me contrate como proveedor de un hogar temporal para adultos si mi nombre aparece como autor en una denuncia vlida.

SignatureApplicant/Firma del solicitante

Date/Fecha

Esta seccin es para el uso del DFPS. To be completed by DFPS be sure to sign and date the bottom of the form. No Match The name of the applicant as stated on this form did not create a match in the DFPS database as a validated perpetrator in an Adult Protective Services (APS) investigation or open investigation. This search only pertains to the applicants name as written on this form. Failure to identify a match does not preclude the possibility that this person is listed on the agency database as a validated perpetrator under another name. Match The name of the applicant as stated on this form DID create a match in the DFPS database as a validated perpetrator in an APS case. Information regarding abuse, neglect or exploitation is as follows:
Type of Maltreatment (check all that apply) Physical Abuse Adult Child Sibling Sexual Abuse Paid Caregiver Verbal Abuse Spouse Neglect Parent Other: Exploitation Case ID: Relationship of Perpetrator to Victim: Date Incident Occurred

Give a brief description of the incident:

Describe APS intervention (if any):

Title of Person Completing Form SignaturePerson Completing Form

Date

Please Return to:

DADS AFC Contract Manager E-mail Address Area Code and Telephone No. Mail Code