STATE OF IOWA
STATE
OF IOWA
DHS CRIMINAL
HISTORY
RECORD CHECK
FORM
FORM BB
TO:
Iowa Division of Criminal Investigations
Bureau of Identification
Wallace State Office Building
Des Moines, Iowa 50319
PURPOSE:
FROM:
X Child Day Care 237A.5, 237A.20
Foster Care/Group Foster Care 237.8
Marsha McBee
Child Care Licensing
Iowa Dept. of Human Services
1200 University Avenue
Des Moines, Iowa 50314
Ph: 515-283-9100 Fax: 515-283-9224
Adoption 600.8(1)(2)
Child Abuse 232.71
Institutions/Facility 218.13
Juvenile Homes 232.142
REQUEST
Center Name and Address
XOCHIPILLI CHILDREN'S CENTER
828 S.E. SCOTT
DES MOINES, IA 50309
I am requesting an Iowa Criminal History (CCH) check on:
Last Name
First Name
Maiden/Former Name, any Alias (List All)
Sex
Middle Name
Social Security Number
Female
Male
Signature of Requester (DHS Employee)
Date of Birth
RESULTS
As of __________________________________________________(date) a name and date of birth check revealed:
CCH record attached
No CCH record found
DCI Initials ___________________
WAIVER
(see reverse side)
I hereby give permission for the above requesting official to conduct an Iowa criminal history check with
the Division of Criminal Investigation. Any information maintained by the DCI may be released as
allowed by law.
Date
Signature
(On file)
Address
595-1396 (8/96)
City, State, ZIP
1
WAIVER:
Iowa law does not require waiver. However, without a waiver any arrest over 18 months old without a
disposition, cannot be given to a non-law enforcement agency.
Deferred judgments where DCI has received notice of successful completion of probation also cannot be
given out to non-law enforcement agencies without a signed waiver.
General Information:
The information requested is based on name and exact date of birth only. Without fingerprints a positive
identification cannot be assured. If a person disputes the accuracy of information maintained by the
Department, they may challenge the information by writing to the address on the front of this form or
personally appearing at DCI headquarters during normal working hours.
The records maintained by the Iowa Department of Public Safety are based upon reports from other
criminal justice agencies and therefore, the Department cannot guarantee the completeness of the
information provided.
The criminal history check is of the Iowa Central Repository only. No other state or federal agency
records can be searched under current law.
In Iowa, a deferred judgment is not considered a conviction once the defendant has been discharged after
successfully completing probation. However, it should be noted that a deferred judgment may still be
considered as an offense when considering charges for certain specified multiple offense crimes, i.e.,
second offense OWI. If a disposition reflects that a deferred judgment was given, you may want to
inquire of the individual his or her current status.
Any questions in reference to Iowa criminal history records can be answered by writing to the address on
the front of this form or calling (515) 281-5138 between 8:00 a.m. and 4:30 p.m., Monday through Friday.
If the “No CCH record found” box is checked, it could also mean that information in the file is not
releasable per Iowa law without a waiver.
Reminder:
Each agency, other than day care, should submit a self-addressed envelope with their requests.
This will expedite the process.
FORM B IS FOR THE SPECIFIC PURPOSE SET OUT ON THE FRONT.
COURT ORDERED HOME STUDY MUST SUBMIT FORM A WITH PAYMENT.
595-1396 (8/96)
2
Record check requests
You may submit the criminal history record checks via e-mail. The signature on the waiver is not
required, because Iowa law does not require evaluation of employees or volunteers on the things that are
released with the signed waiver, i.e. no disposition for any arrest over 18 months old or deferred
judgments where DCI has received notice of successful completion of probation. However, we do ask
that you include the date and the individual's mailing address in that section of the form.
Although a signature is not required, we recommend that you print a hard copy of the form and have the
applicant sign and date it to keep in the employee file as verification for the licensing consultant that you
have submitted the record check request.
The criminal history form is the only form you need to submit to initiate the complete record check. The
results of the criminal history check as well as the child abuse background check and sex offender
registry check will be returned to you by postal mail.
The electronic version of the DHS Criminal History Record Check Form B is attached. You will need to
save the blank document to your computer, then fill in the information for each individual and e-mail
the completed form(s) as attachment(s) to: [email protected] It is not necessary to send
each form as a separate e-mail; you may attach multiple requests to the same e-mail.
Please ensure that all information is included and proofread the forms carefully to make sure
there are no errors.
Please remember to put the center name and mailing address on each form where indicated.
<<DCI Form B - electronic blank.doc>>
Marsha McBee
Child Care Licensing
1200 University Ave
Des Moines IA 50314
Phone 515-283-9100
Fax 515-283-9224
file:///L|/Site%20Information%20and%20Documents/Scanned%20Forms/HERBackgroundCheckInstructions.htm8/17/2007 11:12:01 AM