cps records request form

PS-072-2 (3-06)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Children, Youth and Families
CHILD PROTECTIVE SERVICES RECORDS REQUEST
(Person or agent of a person who is the subject of CPS information)
Child Protective Services (CPS) records are confidential and can be released only to those individuals and agencies permitted by state and federal law. This form is to be used by a person or agent of a person who is the subject of CPS information pursuant to A.R.S. § 8-807(E). You may be asked to provide information to verify your status as a person or agent of a person who is the subject of CPS information. The Department of Economic Security, (DES) will strike out (redact) all personally identifiable information including: the identity of the reporting person, children, parents, relatives, foster parents, persons or entities with whom children reside and any other persons whose life or safety may be endangered by the disclosure. DES is not required to release records that have previously released in the normal course of records distribution in the juvenile court proceeding, without the necessity being demonstrated. You must provide information as completely and accurately as possible to facilitate a record search and processing.
Requester’s Name (Last, First, M.I.) Case Relationship (parent, attorney, agent)
Address
Reason for Request (dependency or termination hearing) Court Number Hearing Date
Record Distribution
Mail
Pick up
Phone No.
Work: ( ) Home: ( )
INVOLVED CHILD(REN)’S NAME BIRTHDATE
Child’s Mother’s Name Social Security Number Date of Birth
Child’s Father’s Name Social Security Number Date of Birth
Other Specific Information Known
I certify that I am the person indicated above and understand that all information I receive is confidential and shall not be further disclosed.
Signature of Person Requesting Information Date
THIS AREA IS FOR AGENCY USE ONLY
Date Request Received Number of Pages Redacting Time Copying Time
Name of Person Redacting Position of Person Redacting Hourly Wage Phone No.
Name of Person Copying Position of Person Copying Hourly Wage Phone No.
Records Were:
Mailed Picked Up Date:
Was Request Denied (If yes reason)
Coordinator’s Signature Date: