State of California-Health and Human Services Agency California Department of Public Health (CDPH)
Licensing and Certification Program (L&C)
Criminal Background Section (CBS)
MS 3304
P.O. Box 997416
Sacramento, CA 95899-7416
(916) 327-2445 Fax: (916) 552-8854
Transmittal Application for
Criminal Record Clearance
Date sent:
(See Live Scan process instructions on reverse)
This form must be completed by the facility administrator or other authorized staff and submitted to the address
above, or faxed using the Live Scan process on reverse. When criminal record clearance is approved, the
individual named below will be cleared for employment or facility licensing purposes. The Department will mail a
criminal record clearance notification to the licensee. The licensee may send a copy of the clearance notification
to the individual as needed. A copy of the clearance notification must be kept on file on the facility premises and
made available to the surveyor during a California Department of Public Health survey or complaint visit.
Type of Intermediate Care Facilities (ICF)/Agency Position of Applicant (check one)
Developmentally Disabled (DD)
Developmentally Disabled Habilitative (DDH)
Developmentally Disabled Nursing (DDN)
Adult Day Health Care (ADHC)
Home Health Agency Licensee (HHL)
Private Duty Nursing Agency (PDN)
Program Director
Direct care staff
Administrator (Manager)
Owner
Fiscal Officer of ADHC
Adult living in facility
Consultant or licensed professional
Name of Individual Applying for Criminal Record Clearance Telephone Number
( )
CDPH 322 (05/14) This form is available on our website at www.cdph.ca.gov Page 1 of 2
-
Developmentally Disabled-Continuous Nursing (DD-CN)
Previous Mailing Address (Number and Street, or P.O. Box Number) City State ZIP CodeYear(s)
Please list below any previous out-of-state address within the past five (5) years.*
( )
-
Facility/Agency Name Facility License Number Telephone Number
Facility/Agency Address (Number and Street, or P.O. Box Number) City State ZIP Code
*If additional fields are required, please use the reverse of this form.
Date of Birth Social Security Number Driver's License Number State
Month Day Year
/ /
ZIP CodeIndividual's Mailing Address (Number and Street, or P.O. Box Number) City State
Applicant Information
Licensee Information
( )
-
Licensee Name Licensee Number Telephone Number
Licensee Address (Number and Street, or P.O. Box Number) City State ZIP Code
Facility/Agency Information
