Below is the form for 365 day request for child care criminal history record check if you have already undergone fingerprinting within the past year.
Complete the top portion of this form, with your contact information, SSN, date of birth, reference number, and signature.
It is critical to include the 12 digit reference number indicating where your most recent background check had been performed (must have been within the previous year).
After your background check, please send the partially completed form to PNS, so that we can fill out the section titled, “TO BE COMPLETED BY NEW EMPLOYER”, and you will be all set.
If you have any questions or difficulties, feel free to contact us.
Epilepsy & Seizure Management
Seizure Documentation Form