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The Texas Criminal History Check Form is a crucial document required by the Texas Department of Aging and Disability Services for those seeking licensure in home and community support services. This form collects essential information about agency owners, administrators, and chief financial officers, ensuring compliance with state regulations. By accurately completing this form, applicants can help facilitate the licensing process and maintain the integrity of services provided to vulnerable populations.

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The Texas Criminal History Check Form is a crucial document for individuals and organizations seeking licensure as Home and Community Support Services Agencies in Texas. This form plays a significant role in ensuring the safety and well-being of vulnerable populations by verifying the backgrounds of key personnel involved in these services. It requires detailed information about the agency's owner, administrators, and chief financial officers, including their names, dates of birth, and any aliases they may have used. Furthermore, it emphasizes the importance of accuracy, as the submission of false information can have serious implications. By signing the form, individuals certify that the information provided is truthful and complete to the best of their knowledge. This form is not only essential for initial licensing but also for renewals and management changes, thereby ensuring that all personnel meet the eligibility criteria set forth by the Texas Health and Safety Code. Additionally, it outlines the rights of individuals regarding the information collected, including the ability to request corrections if any inaccuracies are found. Understanding the nuances of this form is vital for compliance and for maintaining the integrity of services provided to the community.

Dos and Don'ts

When filling out the Texas form for Home and Community Support Services Agencies, consider the following guidelines to ensure accuracy and compliance:

  • Do read the entire form carefully before starting to fill it out.
  • Do use clear and legible handwriting if you are completing the form by hand.
  • Do provide all required information, including full names and dates of birth.
  • Do double-check your entries for spelling and accuracy before submitting.
  • Do sign and date the form to certify the information is correct.
  • Don't leave any sections blank; if something does not apply, indicate that clearly.
  • Don't use abbreviations or nicknames; always use full legal names.
  • Don't submit the form without reviewing it for any potential errors.
  • Don't forget to include any necessary addendums for additional names or information.

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What is the purpose of the Texas Criminal History Check Form?

The Texas Criminal History Check Form is designed to ensure that individuals applying for licensure as Home and Community Support Services Agencies meet the eligibility criteria set forth by the Texas Health and Safety Code. This form collects essential personal information about the agency's owners, administrators, and chief financial officers to conduct background checks and verify their suitability for licensure.

Who needs to complete this form?

This form must be completed by key personnel within the agency, including:

  • Owners
  • Administrators
  • Chief Financial Officers

Each individual must provide their current personal information, including any aliases, date of birth, and race/ethnicity. If any of these individuals have used other names, those should also be included in the form.

How should I submit the form?

After completing the form, submit it along with your initial application, renewal, or change of ownership (CHOW) applications. You can send it by mail or fax to the Texas Department of Aging and Disability Services at the following address:

Texas Department of Aging and Disability Services
Regulatory Services - Agency Licensing
Mail Code E-342
P.O. Box 149030
Austin, TX 78714-9030

For fax submissions, use the number 512-438-2731. If you have questions, you can call 512-438-2630 for assistance.

What rights do I have regarding the information collected?

You have the right to request and be informed about the information that the Texas Department of Aging and Disability Services collects about you. If you believe any information is incorrect, you can ask for corrections. To learn more about your rights and how to request information or corrections, contact Regulatory Services - Agency Licensing at 512-438-2630.

How to Use Texas

Completing the Texas form requires careful attention to detail to ensure that all necessary information is accurately provided. This process is essential for compliance with state regulations and will facilitate the review and approval of your application.

  1. Obtain the Texas Department of Aging and Disability Services Criminal History Check Form.
  2. Begin by filling in the Agency Name at the top of the form.
  3. Provide the Physical Address including street name, city, state, and ZIP code.
  4. Enter the Owner Name in the format of Last, First, Middle.
  5. List the Current License No. and your Area Code and Telephone No.
  6. Indicate if you are the Administrator by checking "Yes" or "No."
  7. Fill in any Other Names Used including married or maiden names and aliases. Use an addendum if necessary.
  8. Input your Date of Birth in the format mm/dd/yyyy.
  9. Select your Race/Ethnicity.
  10. Repeat the steps for the Administrator Name and Chief Financial Officer, ensuring all information is complete and accurate.
  11. Certify the accuracy of the information by signing and dating the form.
  12. Submit the completed form via mail or fax to the Texas Department of Aging and Disability Services at the provided address.

Common mistakes

Filling out the Texas form for Home and Community Support Services Agencies can be straightforward, but there are common mistakes that can lead to delays or complications. One frequent error is failing to complete all applicable sections. It’s crucial to provide detailed information for each required field, including names, addresses, and dates of birth. Incomplete forms may be returned, causing unnecessary setbacks.

Another common mistake is not using the correct format for dates. The form specifically requests dates in the mm/dd/yyyy format. If this format is not followed, the information may be misinterpreted or rejected. Always double-check your entries to ensure they adhere to the specified requirements.

Many individuals also overlook the importance of including all other names used, such as married or maiden names. This section is vital for accurate background checks. Omitting this information can lead to discrepancies and may raise red flags during the licensure process. Always use an addendum if you have multiple aliases.

Additionally, some applicants fail to sign and date the form. This certification is a critical part of the submission. Without a signature, the form is considered incomplete. Ensure that you provide your signature and the date before submitting the form to avoid any issues.

Another mistake is providing incorrect or outdated contact information. It’s essential to list a current phone number and address. If the licensing agency needs to reach you for any reason, having the correct information is vital for timely communication.

Finally, neglecting to submit the form to the correct address can lead to significant delays. Ensure that you send your application to the Texas Department of Aging and Disability Services at the specified mailing address. Double-check the details before sending to avoid misdirection.

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