Idaho
Checklist:Idaho Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Idaho form:https://www.tn.gov/content/dam/tn/human-services/documents/Idaho.pdf
- Please do NOT send this form to Idaho. Please send it to TN DHS, and TN DHS will send it to Idaho.
- Idaho form needs to be notarized.
Email, fax or mail checklist, disclosure form and Idaho form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Illinois
Checklist:Illinois Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Illinois form: https://www.tn.gov/content/dam/tn/human-services/documents/IL_Form_CFS_689.pdf
- *Please note that the Illinois CFS-689 form requires a handwritten ink signature. Illinois rejects forms with electronic signatures.
- *Please do NOT send the CFS-680 to Illinois. TN DHS will send both forms.
Email, fax or mail checklist, disclosure form and Illinois forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Indiana
Checklist:Indiana Checklist
Forms:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
Email, fax or mail checklist and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243
Applicant completes online Indiana form, sent to applicant’s email, after disclosure form has been received in our office
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Iowa
Checklist:Iowa Checklist
Forms:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Iowa form: https://www.tn.gov/content/dam/tn/human-services/documents/IA_Form_470-3301.pdf
- Please do NOT send this form to Iowa. Please send it to TN DHS, and TN DHS will send it to Iowa.
- Please do NOT sign as the requestor. TN DHS signs as the requestor.
Email, fax or mail checklist, disclosure form and Iowa form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Kansas
Checklist:Kansas Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete both Kansas forms: https://www.tn.gov/content/dam/tn/human-services/documents/Kansas%20Adult.pdf
AND
- https://www.tn.gov/content/dam/tn/human-services/documents/Kansas-Child-Form-1011.pdf
- Please do NOT send these forms to Kansas. Please send them to TN DHS, and TN DHS will send them to Kansas.
Email, fax or mail the checklist, disclosure form and both Kansas forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Kentucky
Checklist:Kentucky Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete the Kentucky form: https://www.tn.gov/content/dam/tn/human-services/documents/KYDCC-374-rev.pdf
- *Please note the following when completing the Kentucky form*:
- Please make sure to include full name (i.e., first name, middle name, nick name, maiden name, last name).
- Kentucky requires a witness signature.
- Applicant and witness signature dates must match.
- A clear copy of the applicant’s driver’s license is required.
- Please do NOT send this form to Kentucky. Please send it to TN DHS, and TN DHS will send it to Kentucky.
Email, fax or mail the checklist, disclosure form and both Kentucky forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
Nashville, TN 37243
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Louisiana
Checklist:Louisiana Checklist
Form:for CAN and Criminal
- Complete disclosure form:https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Louisiana form:https://www.tn.gov/content/dam/tn/human-services/documents/LA%20Consent%20Form.pdf
- Please do NOT sign as the requestor. TN DHS signs as the requestor.
- Please note a clear copy of the applicant’s driver’s license is needed.
- Complete Criminal Release Form: LA Criminal Release Form
Email, fax or mail the checklist, disclosure form and both Louisiana forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Maine
Checklist:Maine Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete the Maine form: https://www.tn.gov/content/dam/tn/human-services/documents/Maine-Release-Form.pdf
- Please do NOT send this form to Maine. Please send it to TN DHS, and TN DHS will send it to Maine.
Email, fax or mail the checklist, disclosure form and both Maine forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Maryland
Checklist:Maryland Checklist
Forms:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete the Maryland form: https://www.tn.gov/content/dam/tn/human-services/documents/Maryland%20CPS%20Background%20Form%201279A.pdf
- *Please note the following when completing the Maryland form*:
- Maryland requires that the form be typed.
- Maryland requires the form to be notarized.
- Maryland requires the original form (not a copy, but originally written on in ink).
- Please do NOT send this form to Maryland. Please send it to TN DHS, and TN DHS will send it to Maryland.
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Massachusetts
Checklist:Massachusetts Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete applicant information on Massachusetts form: https://www.tn.gov/content/dam/tn/human-services/documents/Massachusetts%20Form%20-%20received%2003-2023.pdf
- Please do NOT send this form to Massachusetts. Please send it to TN DHS, and TN DHS will send it to Massachusetts.
Email, fax or mail the checklist, disclosure form and both Massachusetts forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Michigan
Checklist:Michigan Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete the Michigan form:https://www.tn.gov/content/dam/tn/human-services/documents/Michigan%20Form%201929-1.pdf
- Please do NOT send this form to Michigan. Please send it to TN DHS, and TN DHS will send it to Michigan.
- Please also note that the signature on the Michigan must be handwritten – it cannot be electronic.
- Please note that Michigan requires a clear copy of the applicant’s driver’s license.
Email, fax or mail the checklist, disclosure form and both Michigan forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Minnesota
Checklist:Minnesota Checklist
Form:for CAN and Criminal
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Minnesota form:https://www.tn.gov/content/dam/tn/human-services/documents/Minnesota.pdf
- Please do NOT send this form to Minnesota. Please send it to TN DHS, and TN DHS will send it to Minnesota.
- The Minnesota form must be notarized.
Email, fax or mail the checklist, disclosure form and both Minnesota forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Mississippi
Checklist:Mississippi Checklist
Form:for CAN and Criminal
- Applicant completes disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- In addition to electronic Identogo fingerprints, the applicant must also get their fingerprints completed in ink, on a hardcopy fingerprint card through their local Police Station, Sheriff’s Office, or vendor of their choice.
- Make a copy of the applicant’s hardcopy ink fingerprint card
- Once these steps are completed: mail original hardcopy fingerprint card (cannot be bent) to:
Mississippi Department of Health
Criminal History Record Check Unit
Attn: Julie Henderson
143B LeFleurs Square
Jackson, MS. 39211
- Also, please email or fax a copy of the applicant’s ink fingerprint card, a clear copy of the applicant’s driver’s license, Mississippi checklist and completed disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956
- When the disclosure form, driver’s license, and copy of the ink fingerprint card are received in the Nashville DHS office, an online Mississippi DocuSign form will be emailed to the applicant’s email address listed on their disclosure form. Please have the applicant watch for this Mississippi DocuSign form in their inbox and junk/spam folders.
- Applicant completes and submits the online Mississippi Child Abuse Registry Check DocuSign Form
*Mailing the hardcopy ink fingerprint card (cannot be bent) via USPS Priority Mail, FedEx, or UPS with a tracking number is recommended.
*TN DHS does not cover the payment for the hardcopy ink fingerprint to be completed or the mail delivery services*
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Missouri
Checklist:Missouri Checklist
Form:for CAN and Criminal
- Applicant completes disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Provider must check whether the applicant is registered in MO’s system (each applicant only needs to be registered once – they will not need to be registered each time a Missouri Background Screening Request is needed).
- Please call 866-422-6872 to verify if applicant is registered (if the applicant needs to be registered, MO will tell you how to do that).
- Please note that if you do have to register the applicant, there is a $14 fee – TN DHS is not authorized to cover or reimburse this fee.
- If the applicant is registered in the system, simply request their background check over the phone (same phone number: 866-422-6872).
- Please Email, fax or mail a copy of the checklist, disclosure form and Missouri Screening results to our Nashville DHS office:
Email, fax or mail the checklist, disclosure form and both Missouri forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.
______________________________________________________________________________________________________________
Montana
Checklist:Montana Checklist
- Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
- Complete Montana form: https://www.tn.gov/content/dam/tn/human-services/documents/MT_Form_CFS_400.pdf
- The Montana form must be notarized.
- Please do NOT send this form to Montana. Please send it to TN DHS, and TN DHS will send it to Montana.
Email, fax or mail the checklist, disclosure form and both Montana forms to:
Email:ccbackground.dhs@tn.gov
Fax: 615-532-9956
Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15thFloor
505 Deaderick Street
*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.