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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective

Date:

Volume:

X

Forms

Chapter:

A

Forms

11-19-2012

Subchapter:

1

Forms

Issuance:

212.A

SBI 212A, Request for Criminal History Record Information for a Noncriminal Justice Purpose

 

Click here to view a sample SBI 212A, Request for Criminal History Record Information for a Noncriminal Justice Purpose.

Contact the Office of Facilities and Support Services, Fingerprint Unit, CC #933, to obtain this form. Do not complete or submit copies of the sample form contained in the manual.

 

PURPOSE AND USE

 

The Request for Criminal History Record Information for a Noncriminal Justice Purpose, State Police Form SBI 212A, is used by DCF to request the State Bureau of Identification (SBI) to complete a computer name check for criminal history information and written documentation of the existence or absence of criminal history of a resource parent applicant or any adult household member of the resource parent applicant's household, potential Civil Service employee/direct care worker or volunteer applicant/student intern.

The SBI 212A is used only when:

      The person had a previous Live Scan and the fingerprint results are no more than 18 months old;

      The Judge requests it for an adoption consent; or

      The person is physically unable to be fingerprinted, for example, the person has no fingerprints or fingers.

 

RESPONSIBILITY OF INITIATING OFFICE

 

The designated DCF staff person submits an SBI 212A form for a criminal history name check on a resource parent, any adult household member of a resource parent's household, potential Civil Service employee/direct care worker or volunteer applicant/student intern to the DCF LiveScan Liaison, Office of Facilities and Support Services, CC 933.

If more than one form is submitted at the same time, arrange the forms in alphabetical order, attach a cover memo identifying the name of the originating office with the number of forms submitted and date the memo.

 

      Maintain a copy of each SBI 212A form and cover memo submitted to the DCF LiveScan Liaison.

      Inform the applicant of any criminal history reported from the State Bureau of Identification involving the applicant or any adult member of their household.

RESPONSIBILITY OF DCF LiveScan Liaison

 

The DCF LiveScan Liaison:

      Receives the Request for Criminal History Record Information for a Noncriminal Justice Purpose, SBI 212A.

      Enters information from SBI 212A into the fingerprint information system.

      Sends request to the State Bureau of Identification.

      Notifies the DCF contact person of any criminal convictions reported from the State Bureau of Identification.

      Sends a confidential memo to the appropriate DCF contact person outlining any criminal convictions listed in the criminal history report.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

The SBI 212A form must be completed accurately in typed format. If the form is not completed fully and accurately, in strict accordance with these instructions, it will be rejected and returned by the LiveScan liaison to be corrected, completed and resubmitted. This process will cause delays in the criminal history background check, and thereby delay the Division's application approval.

 

Complete Name and Address of Requesting Agency

Leave blank. The DCF CFU name and address are pre-printed on the form.

Assigned Identified (ORI Number)

Leave blank. The DCF assigned identification is pre-printed on the form.

Requesting Agency Use Only

Enter the Cost Code Number assigned to the DCF office.

Name

Enter the full name of the applicant, last name, maiden name (if applicable), first name, middle name.

SBI Number (If Known)

Leave blank. Not for DCF use.

Address

Enter the applicant's full address and name of the county.

FBI Number (If Known)

Leave blank. Not for DCF use.

DOB

Enter numerically the applicant's date of birth, month, day and year.

Sex

Identify the applicant's sex by entering "M" for Male, "F" for Female or "B" for Both.

Race

Enter the applicant's race:

W

-

White

A

-

African American

A

-

Asian

H

-

Hispanic

I

-

Native American

O

-

Other

 

Social Security Number

Enter the applicant's Social Security number.

Enter the Appropriate Statute, Rule or Regulation, Executive Order, Administrative Code

Enter the appropriate statute and the designation which applies to this applicant, as indicated below:

 

N.J.S.A. 30:4C-26.8

Resource parent, or an adult household member

N.J.S.A. 30:4-3.6  

Civil Service direct care workers

N.J.S.A. 30:4-3.6  

Civil Service applicants, including volunteers and student interns

 

Authorized Person Making Request

Type or print the name of the person making the request.

Signature of Authorized Person Making Request

The person who makes the request signs the form to indicate approval of the request.

Authorization by Subject...

Complete the following items:

•      Insert Name of Agency to Receive this Information Enter DCF and the office name.

•      Signature The applicant signs and dates the form to authorize the CHRI check.

NOTE

Omission of DOB, Social Security Number, or statute citation and designation will prevent the State Police from retrieving the information on a particular applicant.

 

WHERE TO GET THE FORMS

Request original yellow forms from the DCF LiveScan Liaison, CC 933.

 

DISTRIBUTION

 

Original          -     

DCF LiveScan Liaison (submits to the State Bureau of Identification)

Copy             - 

Resource home record

Copy             - 

Civil Service Employee file

Copy             - 

Volunteer/Student Intern file