Request for staff exclusion list check form: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out request for staff exclusion list check form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the request for staff exclusion list check form in the editor.
Begin with Part 1: Applicant Information. Fill in the applicant's last name, first name, alien registration number (if applicable), and social security number. If no SSN is available, provide the job title and date of birth.
Next, enter the program name and address along with the license or registration number to ensure proper identification of the child care program.
Proceed to Part 2: Authorized Person Information. Input the authorized person's name, work email, facility/provider name, and phone number. Ensure that all details are accurate for effective communication.
Review all entered information for accuracy before submitting. Once confirmed, send the completed form to your licensor/registrar who will forward it to the Justice Center’s Criminal Background Check unit.

Start using our platform today to streamline your document editing and submission process for free!

See more request for staff exclusion list check form versions

We've got more versions of the request for staff exclusion list check form form. Select the right request for staff exclusion list check form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2014	4 Satisfied (48 Votes)
2013	4 Satisfied (20 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

What is the SEL staff exclusion list?

Staff Exclusion List means the register of substantiated cate- gory one cases of abuse or neglect, pursuant to sections 493 and 495 of the Social Services Law.

What is the SEL exclusion list?

The Justice Center maintains a Vulnerable Persons Central Register (VPCR) that includes a Staff Exclusion List (SEL) containing the names of individuals who have committed serious acts of abuse and are deemed ineligible to work in a position involving regular and substantial contact with a service recipient.

What is form i 783?

1-783 (Rev. 03/19/2025) IDENTITY HISTORY SUMMARY REQUEST FORM.

What is a state exclusion list?

Exclusions and debarments are powerful administrative sanctions imposed by Federal and State agencies. They are intended to protect their programs and the beneficiaries they serve by barring the participation of individuals and entities who pose risks to them.