TO:
APPLICANT:

Name: _____________________	Social Security Number: __________
Dates of Employment: __________	Immediate Supervisor: ____________

Our agency [insert name], is requesting information regarding the above- mentioned applicant who is seeking a position. This agency serves children and youth and, accordingly, undertakes background investigations to determine whether the individual poses a risk of harm to those who would be served.

We are interested in receiving any information or records that would reflect on the applicant's fitness to work with children and youth. Please complete the attached EMPLOYER DISCLOSURE AFFIDAVIT and return it to our agency at your earliest convenience. Although any information you wish to provide is welcome, we are especially interested in any conduct, matter, or things that involve an established or reasonable basis for suspecting physical, psychological, or sexual misconduct with respect to children or youth.

You may receive a separate written or telephone request from our agency for an employment reference regarding the applicant. Please respond to each request independently.

With this request is an authorization executed by the applicant. This releases you from any liability for your reply, either in writing or via telephone.

Thank you for your assistance.

Very truly yours,

______________________________

Failure by your agency or organization to provide information requested may result in automatic disqualification of the applicant.

OJJDP Summary: Guidelines for the Screening of Persons Working with Children, the Elderly, and Individuals with Disabilities in Need of Support, April 1998