Article Guide
The California TLR 3 form plays a crucial role in the process of transferring criminal background clearances for caregivers in licensed facilities. This form is essential for ensuring that individuals working with vulnerable populations, such as children or the elderly, have undergone the necessary background checks. To initiate a transfer request, caregivers must provide a valid identification card, which can include a California driver's license, an I.D. card, or even an alien registration card. Key information required on the form includes the caregiver's name, address, and TrustLine registrant ID, along with details about the facility to which they are being transferred. The form also prompts the applicant to declare their association type with the licensed facility, whether as an employee, administrator, or board member, among others. Importantly, the applicant must affirm the truthfulness of their information under penalty of perjury, highlighting the seriousness of the process. Once submitted, the form undergoes verification by county licensing offices, ensuring that all background checks are cleared before the caregiver can assume their role in the facility. This structured approach not only safeguards the well-being of those in care but also reinforces the integrity of the caregiving profession in California.
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY |
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES |
|
COMMUNITY CARE LICENSING DIVISION |
TRUSTLINE TO COMMUNITY CARE LICENSING
CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST
ATTN: CAREGIVER BACKGROUND CHECK BUREAU (CBCB)
A COPY OF ONE OF THE FOLLOWING IDENTIFICATION CARDS MUST BE SUBMITTED WITH THIS TRANSFER REQUEST:
•California Driver’s License
•California I.D. Card
•Alien Registration Card
•A numbered picture I.D. issued from a state other than California
PLEASE TYPE OR PRINT LEGIBLY
DATE:
PLEASE ASSOCIATE THE FOLLOWING TRUSTLINE REGISTRANT:
LAST NAME |
FIRST NAME |
MIDDLE INITIAL
STREET ADDRESS: |
CITY |
STATE |
ZIP CODE: |
CA DRIVER’S LICENSE #:
DOB:
TRUSTLINE REGISTRANT ID#:
SSN: (OPTIONAL)
TO THE FOLLOWING LICENSED FACILITY:
NAME OF FACILITY:
FACILITY NUMBER:
STREET ADDRESS: |
CITY |
STATE |
ZIP CODE: |
TRANSFEREE ASSOCIATION TYPE
■
■
Facility Administrator
Licensee/Applicant
■
■
Corporation Board Member
■
■
Employee
Partnership Member
■
■
Certified Home
Spouse of Licensee
I declare under penalty of perjury that the information provided on this application is true and correct. I understand that any false statements may result in the denial or revocation of my license and/or TrustLine Registration.
SIGNATURE
TITLE (APPLICANT, LICENSEE, ADMINISTRATOR, DIRECTOR)
FOR LICENSING USE ONLY
CII Cleared? ■ YES ■ NO |
FBI Cleared? ■ YES ■ NO |
CACI Cleared? ■ YES ■ NO |
CBCB OR COUNTY EMPLOYEE SIGNATURE
DATE
COUNTY LICENSING OFFICES CAN VERIFY THE STATUS OF TRUSTLINE REGISTRANTS BY CALLING
(916)
TLR 3 (2/11) |
PAGE 1 OF 1 |
Form Specifications
| Fact Name | Description |
|---|---|
| Purpose | The California TLR 3 form is used for transferring a criminal background clearance request for caregivers within licensed facilities. |
| Identification Requirements | A copy of an identification card, such as a California Driver’s License or a state-issued picture ID, must be submitted with the form. |
| Governing Law | This form is governed by California Health and Safety Code, specifically related to community care licensing. |
| Submission Process | The completed form must be sent to the Caregiver Background Check Bureau for processing. |
California Tlr 3: Usage Guidelines
Completing the California TLR 3 form is a straightforward process that requires attention to detail. Once you have filled out the form, it will be submitted to the appropriate licensing authority for processing. Ensure that all information is accurate and legible to avoid any delays.
- Obtain the Form: Download or print the California TLR 3 form from the official website or obtain a physical copy from a local office.
- Fill in the Date: At the top of the form, enter the current date.
- Provide Trustline Registrant Information: Enter the last name, first name, and middle initial of the Trustline registrant. Include the street address, city, state, and ZIP code.
- Enter Identification Details: Fill in the California Driver’s License number and date of birth. Include the Trustline Registrant ID number and Social Security Number (optional).
- Specify the Licensed Facility: Provide the name of the facility and its facility number. Fill in the street address, city, state, and ZIP code of the facility.
- Select Transferee Association Type: Check the appropriate box that describes the relationship to the licensed facility (e.g., Facility Administrator, Employee, etc.).
- Declare Information Accuracy: Read the declaration statement carefully. By signing, you affirm that the information is true and correct.
- Sign and Title: Sign the form and indicate your title (e.g., Applicant, Licensee, Administrator, Director).
- Prepare Identification: Attach a copy of one of the accepted identification cards (e.g., California Driver’s License, Alien Registration Card).
- Submit the Form: Send the completed form and attachments to the Caregiver Background Check Bureau (CBCB) as instructed.
Your Questions, Answered
What is the purpose of the California TLR 3 form?
The California TLR 3 form is used to request the transfer of a criminal background clearance for individuals associated with licensed facilities. This form is essential for caregivers seeking to work in various community care settings, ensuring that they meet the necessary background check requirements. By submitting this form, caregivers can facilitate their transition between different licensed facilities while maintaining compliance with state regulations.
Who needs to submit the TLR 3 form?
What identification is required when submitting the TLR 3 form?
What information must be provided on the TLR 3 form?
What happens if the information on the TLR 3 form is false?
Common mistakes
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Failing to provide a copy of an identification card. It is essential to include one of the accepted forms of ID, such as a California Driver’s License or an Alien Registration Card.
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Not typing or printing legibly. Illegible handwriting can lead to misunderstandings and delays in processing the form.
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Omitting personal information. Ensure that all required fields, such as last name, first name, and date of birth, are filled out completely.
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Incorrectly identifying the licensed facility. Double-check the facility name and number to ensure accuracy, as this information is critical for processing.
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Choosing the wrong transferee association type. It is important to select the correct option that accurately reflects the relationship to the licensed facility.
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Not signing the form. A signature is required to validate the information provided and confirm the declaration of truthfulness.
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Leaving out the date on the form. Including the date helps to establish the timeline of the request and is necessary for processing.
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Providing an incorrect TrustLine Registrant ID. This ID must match the registrant’s official records to avoid confusion.
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Forgetting to include the Social Security Number if applicable. While optional, providing this can assist in verifying identity.
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Neglecting to read the declaration statement thoroughly. Understanding the implications of false statements is crucial to avoid potential penalties.
Documents used along the form
The California TLR 3 form is essential for transferring criminal background clearance for caregivers. Along with this form, several other documents may be required to ensure a smooth process. Below is a list of commonly used forms and documents that complement the TLR 3.
- California Driver’s License: This is a primary form of identification required to verify the identity of the individual submitting the TLR 3 form.
- California I.D. Card: An alternative identification option for those who do not possess a driver’s license, providing similar verification of identity.
- Alien Registration Card: This document serves as proof of legal residency for non-citizens and is necessary for background checks.
- Background Check Consent Form: This form grants permission for the agency to conduct a criminal background check on the individual associated with the TLR 3.
- TrustLine Registration Application: A separate application that registers caregivers with TrustLine, ensuring they meet the necessary qualifications.
- Facility License Application: This document is required for new facilities seeking to operate, ensuring compliance with state regulations.
- Employee Verification Form: Used to confirm the employment status of individuals working within licensed facilities, ensuring they are eligible for caregiver roles.
- Affidavit of Truthfulness: A sworn statement affirming that all information provided in the application and related documents is accurate and truthful.
These documents work together to facilitate the background clearance process and ensure compliance with California regulations. Having them ready can help streamline the transfer and registration process for caregivers and facilities alike.
Similar forms
The California TLR 3 form is important for transferring criminal background clearance requests for caregivers. It shares similarities with other documents used in similar contexts. Here are four documents that are comparable to the TLR 3 form:
- California TrustLine Registration Application: This document is used to register caregivers with TrustLine. Like the TLR 3, it requires personal information and verification of background checks. Both forms aim to ensure safety in caregiving environments.
- Caregiver Background Check Application: This application is specifically for background checks on caregivers. Similar to the TLR 3, it collects identifying information and confirms the individual’s eligibility to work in a caregiving capacity.
- Criminal Background Clearance Request Form: This form is utilized for requesting criminal background checks. It parallels the TLR 3 in that it seeks to ensure that individuals working in care facilities meet safety standards and have cleared necessary checks.
- Facility Licensing Application: This application is used by organizations seeking to operate care facilities. Like the TLR 3, it requires detailed information about individuals associated with the facility and ensures compliance with state regulations.
Dos and Don'ts
When filling out the California TLR 3 form, it’s essential to approach the task with care. Here’s a helpful list of what you should and shouldn’t do to ensure your application is processed smoothly.
- Do provide accurate and complete information. Double-check all entries for correctness.
- Do use clear and legible handwriting or type the information to avoid confusion.
- Do include a copy of an acceptable identification card as specified in the instructions.
- Do sign and date the form to validate your application.
- Don't leave any required fields blank. Incomplete forms can delay processing.
- Don't submit a form without checking for typos or errors.
- Don't forget to specify your association type clearly, as this is crucial for your application.
- Don't provide false information, as this can lead to serious consequences, including denial of your application.
By following these guidelines, you can enhance the chances of a successful transfer request and avoid common pitfalls in the process.
Misconceptions
Understanding the California TLR 3 form is essential for those involved in community care licensing. However, several misconceptions can lead to confusion. Here are four common misunderstandings:
- Misconception 1: The TLR 3 form is only for new applicants.
- Misconception 2: You do not need to submit identification with the form.
- Misconception 3: The form can be submitted without a signature.
- Misconception 4: The TrustLine registration will remain active during the transfer process.
This is not true. The TLR 3 form is designed for transferring existing TrustLine registrants to new licensed facilities. It is used when a caregiver changes their employment or association with a different facility.
In fact, a copy of an identification card is required. Acceptable forms include a California Driver’s License, California I.D. Card, or other specified forms of ID. This helps verify the identity of the registrant.
A signature is mandatory on the TLR 3 form. It certifies that the information provided is accurate and complete. Failing to sign the form can lead to delays or denial of the transfer request.
This is misleading. The TrustLine registration may be put on hold during the transfer until the necessary background checks are completed. It is crucial to ensure that all requirements are met to avoid any interruptions in service.
Key takeaways
When filling out and using the California TLR 3 form, it is essential to follow specific guidelines to ensure a smooth process. Here are key takeaways to keep in mind:
- Identification Requirement: You must submit a copy of an acceptable form of identification. This can be a California Driver’s License, California I.D. Card, Alien Registration Card, or a numbered picture I.D. from another state.
- Legibility Matters: It is crucial to type or print your information clearly. Illegible handwriting can lead to delays in processing your request.
- Accurate Personal Information: Ensure that the details you provide, such as your name, address, and Trustline Registrant ID, are accurate and up to date.
- Facility Information: Include the name and facility number of the licensed facility to which you are transferring. This information is vital for proper processing.
- Association Type: Clearly indicate your association type with the facility. Options include Facility Administrator, Employee, or Spouse of Licensee, among others.
- Declaration of Truthfulness: By signing the form, you declare that all information provided is true and correct. Be aware that false statements can lead to serious consequences, including denial or revocation of your license.
- Licensing Verification: If you need to verify the status of Trustline registrants, you can contact the county licensing offices at the provided phone number.
These takeaways will help you navigate the process of completing the California TLR 3 form effectively. Always double-check your information before submission to avoid unnecessary complications.