Child Welfare Record Request:
Out of State Child Welfare Agencies

This request form is for use by employees, authorized agents, or contract providers of Departments, outside the State of Florida, responsible for carrying out: child protective investigations and/or ongoing child protective services as detailed in § 39.202(2)(l).

PLEASE PROVIDE THE FOLLOWING INFORMATION FOR THOSE PERSONS WHOM FLORIDA CHILD PROTECTIVE HISTORY IS REQUESTED.

Individual 1

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN:

Individual 2

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN:

Individual 3

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN:

Individual 4

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN:

Individual 5

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN:

Individual 6

Last Name: First Name: Maiden Name: DOB: Race: Please Select Asian or Pacific Islander Black, Not of Hispanic Origin Hispanic Origin Native American or Alaska Native Southeast Asian Other Unknown White, Not of Hispanic Origin Sex: Please Select Male Female SSN: