Written Authorization to Request a CAPS Check

This employer is required to request a check of the Colorado Adult Protective Services (APS) data system (CAPS) during the hiring process of new employees who provide direct care to at-risk adults. Additionally, this employer has statutory authority to request a CAPS check for current employees. The CAPS check will alert the employer as to whether or not a prospective or current employee has a substantiated finding as a perpetrator of mistreatment of an at-risk adult, to include physical abuse, sexual abuse, caretaker neglect, and/or exploitation. More information on the CAPS check requirement can be found in the Colorado Revised Statutes (C.R.S.) under §26-3.1-111 and in the Colorado Code of Regulations (CCR) under 12 CCR 2518-01. Written authorization from the applicant/employee using this form is required. Please complete the form in its entirety. Failure to complete the form, omission of pertinent facts, and/or inclusion of misleading facts may result in disqualification or termination of employment. You may keep a copy of this form for your records.

EMPLOYER INFORMATION

Employer Name:(Required)

CAPS Check Employer ID # (XXX-##########):(Required)

REQUESTOR INFORMATION

Requestor Name:(Required)

Requestor Title:(Required)

Requestor Phone Number:(Required)

Requestor Phone Extension:(Required)

Requestor Email:(Required)

APPLICANT/EMPLOYEE INFORMATION

First Name:(Required)

Middle Name:(Required)

Last Name:(Required)

Date of Birth:(Required)

SSN (Last 4 digits):(Required)

Maiden Name/Previous Name(s)/Alias(es):(Required)

DORA License #(Required)

Home Phone (Including Area Code):(Required)

Cell/Mobile Phone (Including Area Code):(Required)

Work Phone (Including Area Code):(Required)

Work Phone Extension:(Required)

Home Email:(Required)

Work Email:(Required)

Current Address Street:(Required)

Current Address City:(Required)

Current State:(Required)

Current Zip/Postal Code:(Required)

Current Address Start Date:(Required)

All Applicants/Employees are required to have 5 years of residential history provided. If the individual listed above has less than 5 years at their current address, please list the previous addresses for the past 5 years. Use another sheet of paper, if necessary.

Previous Address (street number, street, unit, city, state, zip):(Required)

Address Start and End Dates:(Required)

Previous Address (street number, street, unit, city, state, zip):(Required)

Address Start and End Dates:(Required)

Previous Employer(s) Agency Name(s):(Required)

I,(Required)

by my signature below, authorize the employer referenced above to request a CAPS Check to determine if I have a substantiated finding as a perpetrator of mistreatment of an at-risk adult. I acknowledge that a substantiated finding resulting from such a check, unless the finding was expunged through a successful appeal, shall be provided to the person directly involved in the employer’s hiring process and may be used to inform their hiring decision of me. I acknowledge notification may occur through CAPS to this employer, for the duration of my employment with them, of any future substantiated findings against me. I attest that all information provided in this written authorization is true and complete to the best of my knowledge.

Signature(Required)

Date(Required)

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