Forms

Family Care Safety Registry

Worker Registration Form - A person may register by submitting a completed Worker Registration Form, photocopy of their Social Security card and a $9.00 registration fee (if applicable) by check or money order, made payable to Missouri Department of Health and Senior Services. Registrants will receive written notification of their background screening results.

Worker Registration Form

Worker Registration Form      

This form is in Microsoft Word format. For your convenience and future use, the form may be downloaded onto your computer. Select 'Read-only' to open form. When all fields have been completed, please print form, sign and date before submitting to the Family Care Safety Registry.

Employer Background Screening Request Form - Employers use this form to obtain background results at no charge. Employers may submit an Employer Background Screening form along with the Worker Registration form(s) being submitted on employees new to the Registry. Both the employer and employee will receive written notification of the background screening results.

An employer may FAX this form to 573-522-6981.  Both employer and employee will receive results of the background check.

 Employer Background Screening Request Form

Employer Background Screening Request Form

This form is in Microsoft Word format. For your convenience and future use, the form may be downloaded onto your computer. Select 'Read-only' to open form. When all fields have been

completed, please print form, sign and date before submitting to the Family Care Safety Registry.

Internet Access for Providers - Internet access for obtaining background screening results may be granted to a pre-approved provider in good standing with and licensed by or contracted with the Department of Health and Senior Services.  Click How to Become A FCSR Internet User for more information.