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The Georgia 5579 form, officially known as the Residential Child Care Records Check Application, is a crucial document for individuals seeking employment or licensure within residential child care facilities in Georgia. This form is designed for various applicants, including directors, managers, owners, and employees with a criminal history. It requires personal information such as the applicant's name, date of birth, and physical characteristics, along with a detailed disclosure of any criminal history. Additionally, the form must be notarized to ensure the authenticity of the information provided. The director or owner of the residential child care facility also plays a significant role in verifying the applicant's details and indicating the facility's licensing status. Proper completion of this form is essential, as it initiates the background check process, which is a legal requirement for those working with children. The form must be submitted before undergoing a Live Scan fingerprinting process, and failure to do so may result in delays or the inability to receive a determination letter regarding the applicant's eligibility.

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Georgia Department of Human Resources

RESIDENTIAL CHILD CARE

RECORDS CHECK APPLICATION (See Instructions on Back of Form)

TO BE COMPLETED BY APPLICANT:

1. CHECK APPLICANT TYPE:

Director/Manager

Owner

Employee (with criminal history)

2.Print Name ____________________________________________________________________________

 

(Last)

(First)

(Middle)

(Maiden)

(Date of Birth)

________

______

__________________________

________________________

(Sex)

(Race)

(Social Security Number)

 

 

(Place of Birth)

_________ __________ ______________ _____________ __________________________

(Height) (Weight) (Color of Eyes) (Color of Hair) (Home Telephone)

__________________________________________________________________________________

(Mailing Address)

(City)

(State)

(Zip)

3.I hereby authorize the Department of Human Resources and my potential employer named below to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. As required by Law, I have attached an affidavit disclosing the nature and date of any arrest, charge, or conviction, for the violation of any law in any state, except for motor vehicle parking violations.

___________________________________

_____________________________________

(Notary)

(Applicant Signature)

Notary Public ________________, Georgia

My Commission Expires: _________________

(County)

(Date)

TO BE COMPLETED BY OWNER/DIRECTOR OF RESIDENTIAL CHILD CARE FACILITY OR APPLICANT FOR LICENSE:

(PLEASE PRINT CLEARLY)

4. _______________________________________________________________________________________

(PRINT Name of Residential Child Care Facility) (PRINT RCC Address) (PRINT City/Zip Code of PCH)

_______________________________________________________________________________________

(PRINT mailing address, if different from RCC address)

(PRINT City/Zip Code/County Name)

5.THE RESIDENTIAL CHILD CARE FACILITY IDENTIFIED ABOVE: (CHECK ONE)

Is currently licensed.

Is applying for an initial (new) license at the above address.

6.My signature indicates that I, as DIRECTOR/OWNER, have verified the above information on the above applicant.

________________________________________

____________________________________________

(PRINT Name of Director/Owner)

(Telephone of Agency)

_______________________________________

____________________________________________

(Signature of Director/Owner)

(Date)

Form 5579 (Rev.4/18/08) YOU MAY DUPLICATE AND KEEP FOR YOUR RECORDS

Application Instructions

Do not have the Live Scan done before turning in your application package.

1.Please use a ball point pen, press firmly, and PRINT legibly.

2.Please indicate if you are a director/ manager, an owner or an employee (with a criminal history). You should check both owner and director/manager if you are both the administrator and the owner.

3.Print your full name, including your MAIDEN name. DO NOT use initials if your have a given name.

Print your date of birth. Print either: Male or Female.

Print your race: Black, White, or Other. Print your Social Security Number.

Print your place of birth: City or County, State and Country if not USA. Print your height.

Print your weight.

Print the color of your eyes: Do NOT abbreviate: Brown, Black, Grey, Blue, Green, or Hazel.

Print the color of your hair: DO NOT abbreviate: Brown, Black, Grey, Red, Blonde, or Bald. Print your home address.

Print your home telephone number.

4.ALL APPLICATIONS MUST BE NOTARIZED. Read the consent statement.

Sign your name as you would on a bank check or business letter.

DIRECTOR/OWNER WILL COMPLETE THE FOLLOWING

5.Record check results will be mailed to the address that is entered here. Print clearly and give complete mailing address.

Indicate name of your facility as it appears on your permit or permit application. Print the address of the Residential Child Care Facility.

Print the mailing address where the letter of determination is to be sent. Print the city/zip/county.

6.Check the correct box to indicate current licensure status for your Residential Child Care facility.

7.Director or Owner must sign his/her name as it would appear on a bank check or business letter.

8.This form must be completed and brought with you for Live Scans at 2 Peachtree or specified DHR-DFCS offices OR, if the Live Scan is done at a COGENT/GAPS location, this form must be mailed to:

Office of Investigative Services

Background Investigations Unit

2 Peachtree Street, N.W., Suite 30.482

Atlanta, GA. 30303-3142

9.If the Criminal Records Check Application is not received by OIS, you will not receive a determination letter.

10.This form should be sent to OIS before the fingerprinting at the COGENT/GAPS location is done.

Form Specifications

Fact Name Details
Form Purpose This form is used to apply for a background check for individuals working in residential child care facilities in Georgia.
Applicant Types Applicants can be directors, managers, owners, or employees with a criminal history.
Notarization Requirement All applications must be notarized to be valid.
Governing Law The form is governed by Georgia state laws regarding background checks for child care providers.
Personal Information Applicants must provide detailed personal information, including their full name, date of birth, and social security number.
Live Scan Instructions Do not complete the Live Scan before submitting the application package.
Submission Address Completed forms must be sent to the Office of Investigative Services at 2 Peachtree Street, N.W., Atlanta, GA.
Licensure Status Applicants must indicate whether the residential child care facility is currently licensed or applying for a new license.
Processing Time If the application is not received by the Office of Investigative Services, no determination letter will be issued.

Georgia 5579: Usage Guidelines

Completing the Georgia 5579 form is a necessary step for individuals seeking a residential child care records check. This form must be filled out accurately to ensure the processing of your application. Follow these steps carefully to complete the form correctly.

  1. Check Applicant Type: Indicate whether you are a Director/Manager, Owner, or Employee (with criminal history).
  2. Print Your Name: Fill in your last name, first name, middle name, and maiden name, if applicable.
  3. Date of Birth: Enter your date of birth.
  4. Gender and Race: Specify your sex (Male or Female) and race (Black, White, or Other).
  5. Social Security Number: Provide your Social Security Number.
  6. Place of Birth: Indicate your place of birth, including city or county, state, and country if not the USA.
  7. Physical Attributes: Fill in your height, weight, color of eyes, and color of hair without abbreviations.
  8. Home Telephone: Provide your home telephone number.
  9. Mailing Address: Enter your complete mailing address, including city, state, and zip code.
  10. Authorization: Read the consent statement and sign your name as you would on a bank check or business letter.
  11. Notarization: Have the form notarized by a Notary Public in Georgia.
  12. Facility Information: Print the name and address of the Residential Child Care Facility.
  13. Licensure Status: Check the appropriate box to indicate if the facility is currently licensed or applying for a new license.
  14. Director/Owner Verification: The Director/Owner must print their name, provide their agency telephone number, sign, and date the form.
  15. Submission: Bring the completed form to your Live Scan appointment or mail it to the specified address if using a COGENT/GAPS location.

After completing the form, ensure that all information is accurate and legible. Submit the form as instructed, and await further communication regarding your application status.

Your Questions, Answered

What is the purpose of the Georgia 5579 form?

The Georgia 5579 form is used to apply for a residential child care records check. It helps ensure that individuals who work in child care facilities do not have a criminal history that could pose a risk to children. This form must be completed by applicants seeking employment or licensure in residential child care settings.

Who needs to fill out the Georgia 5579 form?

What information is required on the form?

Applicants need to provide personal details such as their full name, date of birth, sex, race, social security number, place of birth, height, weight, eye color, hair color, home telephone number, and mailing address. Additionally, the form requires a signature and notarization to validate the application.

How should I complete the form?

Use a ballpoint pen and print legibly. Make sure to include your maiden name if applicable. Avoid using initials for your given name. After filling out the form, you must sign it in the presence of a notary public to ensure it is legally binding.

Where do I send the completed form?

If you are having a Live Scan done at a specified DHR-DFCS office, bring the completed form with you. If the Live Scan is done at a COGENT/GAPS location, mail the form to the Office of Investigative Services, Background Investigations Unit, at 2 Peachtree Street, N.W., Suite 30.482, Atlanta, GA 30303-3142.

Is notarization required for the Georgia 5579 form?

Yes, notarization is required. All applications must be notarized to be considered valid. This step is crucial for confirming the identity of the applicant and the accuracy of the information provided.

What happens if I do not submit the form before my Live Scan?

If the Criminal Records Check Application is not received by the Office of Investigative Services before the Live Scan, you will not receive a determination letter. It is essential to submit the form in advance to avoid delays in the background check process.

How will I receive the results of my background check?

The results of the background check will be mailed to the address you provide on the form. Ensure that the mailing address is complete and accurate to avoid any issues with receiving your results.

What should I do if I have a criminal history?

If you have a criminal history, you must disclose this information on the form by attaching an affidavit that details the nature and date of any arrest, charge, or conviction, excluding minor motor vehicle parking violations. Transparency is important for the review process.

Common mistakes

  1. Neglecting to notarize the application. All applications must be notarized. Failure to do so will result in processing delays.

  2. Using initials instead of full names. It is crucial to print your full name, including your maiden name. Using initials can lead to confusion and potential rejection of the application.

  3. Omitting required personal information. Ensure you provide all requested details, including date of birth, race, and Social Security Number. Missing information can halt the application process.

  4. Failing to indicate the correct applicant type. Clearly check the box for whether you are a director, owner, or employee. Misidentifying yourself can complicate your application.

  5. Not printing legibly. Use a ballpoint pen and print clearly. Illegible handwriting can lead to misunderstandings and delays.

  6. Incorrectly completing the mailing address. Make sure to provide a complete and accurate mailing address for the record check results. Errors here can cause important documents to be sent to the wrong location.

  7. Not checking the current licensure status. Ensure you check the appropriate box regarding the licensing status of the residential child care facility. This is vital for the processing of your application.

  8. Submitting the form without a signature. The director or owner must sign the application as it would appear on a bank check. An unsigned form will not be accepted.

  9. Sending the form after Live Scan. The application must be submitted before the fingerprinting process. Delaying this step can result in a denial of your application.

Documents used along the form

The Georgia 5579 form is an essential document for individuals seeking to work in residential child care facilities in Georgia. It serves as a request for a criminal history check, ensuring that the safety and well-being of children are prioritized. Along with this form, there are several other documents that are commonly used in the application process. Below is a list of these forms and documents, each accompanied by a brief description.

  • Affidavit of Disclosure: This document is required to accompany the Georgia 5579 form. It provides details about any past arrests, charges, or convictions, excluding minor motor vehicle violations. This affidavit helps ensure transparency in the application process.
  • Live Scan Fingerprint Form: This form is necessary for scheduling a fingerprinting appointment. It captures the applicant's fingerprints electronically, which are then used to conduct a thorough background check through various criminal justice databases.
  • Background Check Consent Form: This form grants permission for the Department of Human Resources to access the applicant's criminal history. It is a critical step in ensuring that all relevant information is available for review.
  • Employment Verification Form: Often required by employers, this document verifies the applicant's previous employment history. It may include details such as job titles, dates of employment, and reasons for leaving past positions.
  • Child Care Facility License Application: If the applicant is seeking to operate a new residential child care facility, this application must be submitted. It includes information about the facility, its location, and compliance with state regulations.
  • Health and Safety Compliance Form: This document ensures that the residential child care facility meets all health and safety standards as mandated by state regulations. It may require inspections and certifications to be attached.

Each of these documents plays a vital role in the application process for working in or operating a residential child care facility in Georgia. Together, they help maintain the integrity and safety of child care services in the state.

Similar forms

The Georgia 5579 form, which is used for Residential Child Care Records Check Applications, shares similarities with several other documents. Below is a list of ten forms that are comparable in purpose or function:

  • Child Care Licensing Application: This form is also used to apply for a license to operate a child care facility, requiring personal information and background checks.
  • Background Check Authorization Form: Similar to the Georgia 5579, this document allows an employer to obtain a person's criminal history from law enforcement agencies.
  • Employee Application for Employment: This form gathers personal details and may include consent for background checks, similar to the information requested in the Georgia 5579.
  • Foster Care Application: Like the 5579, this application requires background checks and personal information to ensure the safety of children in care.
  • Volunteer Background Check Form: This document is used to authorize background checks for individuals who wish to volunteer in child care settings, paralleling the intent of the Georgia 5579.
  • Adoption Application: This form collects personal and background information to ensure the suitability of individuals seeking to adopt, much like the Georgia 5579.
  • Residential Treatment Center Application: Similar in nature, this application is for those seeking to operate a facility that provides care for children with special needs, requiring background checks.
  • School Employee Background Check Form: This form allows schools to conduct background checks on potential employees, sharing the same goal of ensuring child safety.
  • Child Protective Services (CPS) Background Check: This document is used to check the history of individuals who may work with children, similar to the process outlined in the Georgia 5579.
  • Health Care Provider Background Check Form: This form is used to verify the backgrounds of individuals working in health care settings, ensuring the safety of vulnerable populations, akin to the Georgia 5579.

Dos and Don'ts

When filling out the Georgia 5579 form, it’s important to follow specific guidelines to ensure your application is processed smoothly. Here are six essential dos and don’ts:

  • Do use a ballpoint pen and print clearly.
  • Do include your full name, including your maiden name, and avoid using initials.
  • Do ensure all sections are completed, including your height, weight, and hair color without abbreviations.
  • Do have your application notarized before submission.
  • Don’t forget to check the appropriate box for your applicant type (Director/Manager, Owner, Employee).
  • Don’t submit the form without verifying that all information is accurate and complete.

By adhering to these guidelines, you can help prevent delays in the processing of your application.

Misconceptions

There are several misconceptions about the Georgia 5579 form. Understanding these can help applicants navigate the process more effectively. Here’s a list of common misunderstandings:

  • It's only for employees. Many believe this form is solely for employees. In reality, it is for directors, managers, owners, and employees with a criminal history.
  • Notarization is optional. Some think notarization is not necessary. However, all applications must be notarized to be valid.
  • Only criminal history matters. Many applicants focus only on their criminal history. The form also requires personal details like height, weight, and hair color.
  • Live Scan can be done anytime. Some people assume they can complete the Live Scan whenever they want. In fact, it should not be done before submitting the application package.
  • Providing initials is acceptable. Some believe using initials for their name is sufficient. The form specifically requires full names, including maiden names.
  • Address details are not important. Many overlook the importance of providing a complete mailing address. This is crucial for receiving the determination letter.
  • All facilities are automatically licensed. Some assume their facility is licensed without checking. The form requires applicants to indicate their current licensure status.
  • Only one signature is needed. There is a misconception that only the applicant’s signature is necessary. The director or owner must also sign the form.
  • Submitting the form is the last step. Many think that once they submit the form, their job is done. In reality, it must be sent before fingerprinting to ensure proper processing.

Being aware of these misconceptions can help streamline the application process and ensure compliance with all requirements.

Key takeaways

Here are some key takeaways for filling out and using the Georgia 5579 form:

  • Complete All Sections: Ensure every section of the form is filled out accurately. Missing information can delay the process.
  • Notarization Required: Remember that all applications must be notarized. This step is essential for the validity of your application.
  • Provide Full Name: Print your full name, including your maiden name. Avoid using initials to prevent confusion.
  • Indicate Your Role: Clearly check the box that corresponds to your role—Director/Manager, Owner, or Employee (with criminal history).
  • Mailing Address Matters: The results will be mailed to the address you provide. Make sure it is complete and accurate.
  • Follow Submission Guidelines: Submit the form before your Live Scan appointment. If done at a COGENT/GAPS location, mail the form to the specified address.