CPI/CPS Request

Which party is initiating this request?

Self - CPI/CPS Checks are allowed no more than every 6 months per person.
What type of Organization is requesting this CPI/CPS check?

If Other, please explain:
Reason(s) for history check: Self DCS CPS Background Check.
Reason(s) for history check:

"Employment" and/or "Volunteer" may not be selected with any other Reason(s). For example: "Volunteer and Foster Family Licensing" may not be selected on the same Request. A separate Request for "Volunteer" and a separate Request for "Foster Family Licensing" will be created by the Organization.

If Other, please explain:

County Details:

Foster Family Home:

Wardship County:
Is the Request in association with an ongoing/pending investigation or assessment?
Yes No
Assessment ID or Number/Comments:

Out-of-State (OOS) Child Welfare Agencies submitting Indiana CPS History Check Requests must complete a separate form for each person. Please enter your State's reference number, assessment number or other identifying information in the cell to the left.