Fillable Printable Bhs Policy Attachment 406 5
Fillable Printable Bhs Policy Attachment 406 5
Bhs Policy Attachment 406 5
Policy 406,
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVIT
Revised 07/17/09
Page 1 of 6
Applicant’s Name (First, Middle, Last) Social Security Number Birth Date Area Code and Phone #
Applicant’s Address (#, Street, City, State, Zip)
Facility Name
Facility Address (#, Street, City, State, Zip)
A.R.S. § 8-201. Definitions
13. “Dependent child”:
In this title, unless the context otherwise requires:
(a) Means a child who is adjudicated to be:
(i) In need of proper and effective parental care and control and who has no parent or guardian, or
one who has no parent or guardian willing to exercise or capable of exercising such care and
control.
(ii) Destitute or who is not provided with the necessities of life, including adequate food, clothing,
shelter or medical care.
(iii) A child whose home is unfit by reason of abuse, neglect, cruelty or depravity by a parent, a
guardian or any other person having custody or care of the child.
(iv) Under the age of eight years and who is found to have committed an act that would result in
adjudication as a delinquent juvenile or incorrigible child if committed by an older juvenile or
child.
(v) Incompetent or not restorable to competency and who is alleged to have committed a serious
offense as defined in section 13-604.
(b) Does not include a child who in good faith is being furnished Christian Science treatment by a duly
accredited practitioner if none of the circumstances described in subdivision (a) of this paragraph exists.
Pursuant to A.R.S. § 36-425.03 (K) For the purposes of this section:
1. "Children's behavioral health program" means a program that provides children's behavioral health services
and that is licensed by the department as a b ehavi oral h ealth serv ice agen c y or that contracts with the
department to provide children's behavioral health services.
2. "Children's behavioral health program personnel" means an owner, employee or volunteer who works at a
children's behavioral health program.
Pursuant to A.R.S. § 36-425.03, (E) Forms submitted pursuant to subsection D of this section are confidential.
Pursuant to A.R.S. § 36-425.03(D) Children's behavioral health program personnel shall certify on forms that
are provided by the department and notarized that they are not awaiting trial on or have never been convicted of
or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-
1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction.
Pursuant to A.R.S. § 36-425.03 (G) a pers on w ho i s await ing trial on or who has been convicted of or who has
admitted in open court or pursuant to a plea agreement to committing a criminal offense listed in subsection D,
of this section is prohibited from workin g in an y capaci t y in a children’s behavioral health program that requires
or allows contact with children.
Policy 406,
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVIT
Revised 07/17/09
Page 2 of 6
Pursuant to A.R.S. § 36-425.03(H), a person who is awaiting trial on or who has been convicted of or who has
admitted in open court or pursuant to a plea agreement to committing a criminal offense listed in subsection D,
of this section shall not work in a children’s behavioral health program in any capacity that requires or allows
the employee to provide direct services to children unless the person has applied for and received the required
fingerprint clearance card pursuant to title 41, chapter 12, article 3.1.
Pursuant to A.R.S. § 36-425.03 (J) the employer shall notify the department of public safety if the employer
receives credible evidence that a person who possesses a valid fingerprint clearance card either:
1. Is arrested for or charged with an offense listed in A.R.S. § 41-1758.03(B).
2. Falsified information on the form required by subsection D of this section.
A.R.S. § 41-619.55 (I) Good cause exceptions; revocation
Pending the outcome of a good cau se exce ption determination, the board or its hearin g office r may issue interim
approval in accordance with board rule to continue working to a good cause exception applicant.
A.R.S. § 36-425.03(D) and A.R.S. § 41-1758.03 (B) Fingerprint cl eara nce ca rds; iss uan ce: A person who is
subject to registration as a sex offender in this state or any other jurisdiction or who is awaiting trial on or who
has been convicted of committing or attempting, soliciting, facilitating or conspiring to commit one or more of
the following offenses in this state or the same or similar offenses in another state or jurisdiction is precluded
from receiving a fingerprint clearance card:
Yes No
1.
Sexual abuse of a vulnerable adult.
2. Incest.
3. First or second-degree murder.
4. Sexual assault.
5. Sexual exploitation of a minor.
6. Sexual exploitation of a vulnerable adult.
7. Commercial sexual exploitation of a minor.
8. Commercial sexual exploitation of a vulnerable adult.
9. Child prostitution as prescribed in section 13-3212.
10. Child abuse.
11. Abuse of a vulnerable adult.
12. Sexual conduct with a minor.
13. Molestation of a child.
14. Molestation of a vulnerable adult.
15. Sex trafficking.
Policy 406,
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVIT
Revised 07/17/09
Page 3 of 6
Yes No
16. Sexual abuse.
17. Production, publication, sale, possession and presentation of obscene items as
prescribed in section 13-3502.
18. Furnishing harmful items to minors as prescribed in section 13-3506.
19. Furnishing harmful items to minors by internet activity as
prescribed in section 13-3506.01.
20. Obscene or indecent telephone communications to minors for commercial
purposes as prescribed in section 13-3512.
21. Luring a minor for sexual exploitation.
22. Enticement of persons for purposes of prostitution.
23. Procurement by false pretenses of person for purposes of prostitution.
24. Procuring or placing persons in a house of prostitution.
25. Receiving earnings of a prostitute.
26. Causing one’s spouse to become a prostitute.
27. Detention of persons in a house of prostitution for debt.
28. Keeping or residing in a house of prostitution or employment in prostitution.
29. Pandering.
30. Transporting persons for the purpose of prostitution, polygamy and concubinage.
31. Portraying adult as a minor as prescribed in section 13-3555.
32. Admitting minors to public displays of sexual conduct as prescribed in section
13-3558.
33. A dangerous crime against children as defined in section 13-604.01.
34. Exploitation of minors involving drug offenses.
35. Taking a child for the purpose of prostitution as prescribed in section 13-3206.
36. Neglect or abuse of a vulnerable adult.
37. Unlawful sale or purchase of children.
38. Child bigamy.
A.R.S. § 36-425.03(D) and A.R.S. § 41-1758.03 (C) A person who is awaiting trial on or who has been
convicted of committing or attempting, soliciting, facilitating or conspiring to commit one or more of the
following offenses in this state or the same or similar offenses in another state or jurisdiction is precluded from
Policy 406,
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVIT
Revised 07/17/09
Page 4 of 6
receiving a fingerprint clearance card, except that the person MAY petition the board of fingerprinting for a
good cause exception pursuant to section 41-619.55:
Yes No
1.
Manslaughter.
2. Endangerment.
3. Threatening or intimidating.
4. Assault.
5. Unlawfully administering intoxicating liquors, narcotic drugs or dangerous drugs.
6. Assault by vicious animals.
7. Drive by shooting.
8. Assaults on officers or fire fighters.
9. Discharging a firearm at a structure.
10. Indecent exposure.
11. Public sexual indecency.
12. Aggravated criminal damage
13. Theft.
14. Theft by extortion.
15. Shoplifting.
16. Forgery.
17. Criminal possession of a forgery device.
18. Obtaining a signature by deception.
19. Criminal impersonation.
20. Theft of a credit card or obtaining a credit card by fraudulent means.
21. Receipt of anything of value obtained by fraudulent use of a credit card.
22. Forgery of a credit card.
23. Fraudulent use of a credit card.
24. Possession of any machinery, plate or other contrivance or incomplete credit card.
25. False statement as to financial condition or identity to obtain a credit card.
26. Fraud by persons authorized to provide goods or services.
27. Credit card transaction record theft.
28. Misconduct involving weapons.
Policy 406,
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVIT
Revised 07/17/09
Page 5 of 6
Yes No
29. Misconduct involving explosives.
30. Depositing explosives.
31. Misconduct involving simulated explosive devices.
32. Concealed weapon violation.
33. Possession and sale of peyote.
34. Possession and sale of a vapor-releasing substance containing a toxic substance.
35. Sale of precursor chemicals.
36. Possession, use or sale of marijuana, dangerous drugs or narcotic drugs.
37. Manufacture or distribution of an imitation controlled substance.
38. Manufacture or distribution of an imitation prescription-only drug.
39. Manufacture or distribution of an imitation over-the-counter drug.
40. Possession or possession with intent to use an imitation controlled substance.
41. Possession or possession with intent to use an imitation prescription-only drug.
42. Possession or possession with intent to use an imitation over-the-counter drug.
43. Manufacture of certain substances and drugs by certain means.
44. Adding poison or other harmful substance to food, drink or medicine.
45. A criminal offense involving criminal trespass and burglary under title 13, chapter
15.
46. A criminal offense under title 13, Chapter 23.
47. Child neglect.
48. Misdemeanor offenses involving contributing to the delinquency of a minor.
49. Offenses involving domestic violence.
50. Arson.
51. Kidnapping.
52. Fel o ny of f enses involvin g sale, distribution or tra nsportation of, offer t o sel l,
transport or distribute or conspirac y t o sell, transport or distribute marijuana,
dangerous drugs or narcotic drugs.
53. Robbery.
54. Aggravated assault.
55. Felony offenses involving contributing to the delinquency of a minor.
56. Negligent homicide.
57. Criminal damage.
Revised 07/17/09
Page 6 of 6
Attachment 5
ARIZONA DEPARTMENT OF HEALTH
DIVISION OF BEHAVIORAL HEALTH
POLICY OFFICE
COMMUNITY SERVICE AGENCY CRIMINAL HISTORY AFFIDAVI
T
No
Yes
58.
Misappropriation of charter school monies as prescribed in section 13-1818.
59. Taking identity of another person or entity.
60. Aggravated taking identity of another p erson or entit y.
61. Trafficking in the identity of another person or entity.
62. Cruelty to animals.
63. Prostitution.
64. Sale or distribution of material harmful to minors through vending machines as
prescribed in section 13-3513.
65. Welfare fraud.
Applicant’s Name (print)
NOTARIZATION
I hereby certify under penalty of perjury that the answers given above are true and correct to the best of my
knowledge and belief.
Applicant’s Signature
)
State of Arizona, County of
)
)ss
Subscribed and sworn before me, a Notary Public, this day of , 20 .
My Commission Expires: .
Notary Public’s Signature
