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VDSS Form

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INSTRUCTIONS

Purpose
The Virginia Child Abuse and Neglect Central Registry is mandated by the Virginia Child Protective Law and contains the names of individuals identified as an abuser or neglector in founded child abuse and/or neglect investigations conducted in the state of Virginia. The findings are made by Child Protective Services staff in local departments of social services and are maintained by the Virginia Department of Social Services. Legal mandates for the Virginia Department of Social Services to provide a Central Registry and a mechanism for conducting searches of the registry are found in § 63.2-1515 of the Code Virginia.

Read all instructions before completing the form: (Incomplete forms will be returned)

  1. Answer all questions completely and accurately by printing clearly in black ink or typing your answers. Failure to complete or print clearly may delay or deny your request. Given the nature of the form and the actions to be taken when received, the Office of Background Investigations shall not accept forms that have been altered in any fashion. Forms that contain strike outs, correction tape or white-out will be returned.
  2. If a middle name is an initial, indicate “initial only” otherwise, enter a full middle name given at birth.
  3. For “other names used” list all previous names; nick names, all previous married names, legal name changes, changes due to adoption, etc. Circle appropriate title description on the form.
  4. If the answer to any question is none, write “N/A“.
  5. Sign the Central Registry Release of Information Form in the presence of an official Notary Public. Each request form must be notarized. Only original signatures will be accepted. No copies of the form will be accepted.
  6. A $10.00 fee is charged for each search. Payment must accompany search forms. Only money orders, company/business checks, or cashier checks will be accepted. (If multiple requests are mailed together, payment may be combined on in one money order, company/business check, or cashier’s check. (ex. 4 requests at $10.00 each will total $40.00). A $50 fee will be charged for all returned checks.) All money orders, company/business checks, or cashier checks should be made payable to: Virginia Department of Social Services. Personal checks and cash will not be accepted.
  7. For agencies and facilities that require several searches per year, an agency code will be assigned to expedite processing of the search requests.
  8. If additional space is needed to complete the form (ie. providing information on addresses, spouses, and children) attach an 8x11 sheet sheet of paper along with your form to be mailed.
  9. Search results are not transferable and are not considered official beyond the requesting agency or individual.
  10. Mail your completed form and additional sheets (if used) to: Virginia Department of Social Services Office of Background Investigations - Search Unit 801 East Main Street, 6th Floor Richmond, VA 23219-2901
Purpose of Search, Check one:*

MAIL SEARCH RESULTS TO: Agency, Individual or Authorized Agent Requesting Search

Name*
Address*
Name*
Mandatory if agency code has been assigned

PART I: DETAILS OF INDIVIDUAL WHOSE NAME MUST BE SEARCHED

Name*
Sex*
MM slash DD slash YYYY

Applicant’s Prior Addresses

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Marital Status*
If married, list current spouse. If previously married, list all previous spouses. If you have never been married, write ‘N/A’.
Name*
Sex*
MM slash DD slash YYYY
Name*
Sex*
MM slash DD slash YYYY
Name*
Sex*
MM slash DD slash YYYY

List all of your children.

If you have none, write ‘N/A’. Include all adult children, step and foster children not living with you.
Name*
Sex*
MM slash DD slash YYYY
Name*
Sex*
MM slash DD slash YYYY
Name*
Sex*
MM slash DD slash YYYY

PART II: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION

I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge. Pursuant to Section 2.2-3806 of the Code of Virginia, I authorize the release of personal information regarding me which has been maintained by either the Virginia Department of Social Services or any local department of social services which is related to any disposition of founded child abuse/neglect in which I am identified as responsible for such abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this in his/her presence.
Clear Signature
(Sign in presence of Notary)
Clear Signature
(Sign in presence of Notary)

PART III: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL

Clear Signature
Clear Signature

PART IV: CENTRAL REGISTRY FINDINGS – COMPLETED BY CENTRAL REGISTRY STAFF ONLY

Clear Signature
OBI Staff Only
MM slash DD slash YYYY
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