470-0643 (Rev. 2/16)	Copy 1: Central Registry or Designee	Copy 2: County Office

Iowa Department of Human Services
Request for Child and Dependent Adult Abuse Information
Persons or agencies with authorized access to child or dependent adult abuse information must use this form to request information about a child or dependent adult abuse report. Complete a separate form for each family or individual and email to dhsabuseregistry@dhs.state.ia.us, or fax to (515) 564-4112, or mail to the Iowa Department of Human Services, Central Abuse Registry, P.O. Box 4826, Des Moines, IA 50305.
Please specify your type of request by checking the appropriate box below:

Child abuse request	Dependent adult abuse request	Both

Please specify your preferred method of response by checking a box and completing the information in Section 1. Address	Fax	Email
Section 1: To be completed by the person or agency requesting the information.	
Requester: Last  Jones	First  Marilyn	
Agency Name  Clarke University	Telephone Number
(563	)588-6361	
Address
1550 Clarke Drive	Fax Number
(563	)584-8684	
City
Dubuque 	State
IA	Zip Code
52001	Email
Marilyn.jones@clarke.edu	
Relationship to the persons listed in Section 2 or 3:  Nursing Students	
Purpose for request: Part of the application for entrance into the Nursing Program	
State the Iowa Code section that allows access to the child or dependent adult abuse information requested:	
I have read and understand the legal provisions for handling child or dependent adult abuse information which is printed on the second page of this form. I understand that this request will not be approved unless I have authorized access.	
Signature of Requester	Date	

Complete Section 2 if the purpose of this record check is employment, licensing or registration, or payment approval.
Section 2: List the name and address of the person whose record is being checked.	
Last	First	Middle	Birth Date	Social Security Number	
Address	City	County	State	Zip Code	
List maiden name, any previous married names, and any alias:	

Complete Section 3 if the request is for a copy of the written summary of the abuse investigation or assessment.
Section 3: List the name of the persons for whom you are requesting information. Attach pages for additional family members.
Last	First	Middle	County	Birth Date	Social Security #	

Address	City	State	Zip Code	
List maiden name, any previous married names, and any alias:	

Section 4: Registry or designee decision.		

This request for information is approved.
This request for information is denied because:
Signature of Registry or Designee	Date	

470-0643 (Rev. 2/16)	Copy 1: Central Registry or Designee	Copy 2: County Office

LEGAL PROVISIONS FOR HANDLING
CHILD AND DEPENDENT ADULT ABUSE INFORMATION
Redissemination of Child and Dependent Adult Abuse Information
(Iowa Code sections 235A.17 and 235B.8)
A person, agency, or other recipient of child or dependent adult abuse information shall not redisseminate (release) this information, except that redissemination is permitted when ALL of the following conditions apply:
	The redissemination is for official purposes in connection with prescribed duties or, in the case of a health practitioner, pursuant to professional responsibilities.
	The person to whom such information would be redisseminated would have independent access to the same information under Iowa Code sections 235A.15 or 235B.6.
	A written record is made of the redissemination, including the name of the recipient and the date and purpose of the redissemination.
	The written record is forwarded to the Central Abuse Registry within 30 days of the redissemination. Criminal Penalties (Iowa Code sections 235A.21 and 235B.12)
A person is guilty of a criminal offense when the person:
	Willfully requests, obtains, or seeks to obtain child or dependent adult abuse information under false pretenses, or
	Willfully communicates or seeks to communicate child or dependent adult abuse information to any agency or person except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8, or
	Is connected with any research authorized pursuant to Iowa Code sections 235A.15 and 235B.6 and willfully falsifies child or dependent adult abuse information or any records relating to child or dependent adult abuse.
Upon conviction for each offense, the person is guilty of a serious misdemeanor punishable by a fine or imprisonment.
Any person who knowingly, but without criminal purposes, communicates or seeks to communicate child or dependent adult abuse information except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8 is guilty of a simple misdemeanor punishable, upon conviction for each offense, by a fine or imprisonment.
Any reasonable grounds for belief that a person has violated any provision of Iowa Code Chapters 235A or 235B shall be grounds for the immediate withdrawal of any authorized access that person might otherwise have to child or dependent adult abuse information.
REQUESTS FOR CORRECTION OR EXPUNGEMENT OF A
CHILD OR DEPENDENT ADULT ABUSE REPORT
To request an administrative appeal hearing of a child or dependent adult abuse report, please submit a request in writing to: Department of Human Services, Appeals Section, 5th Fl, 1305 E Walnut St, Des Moines, Iowa 50319-0114. You will be notified in writing acknowledging receipt of your request; time, date, and place of your hearing; and any decisions regarding your request. If you disagree with this decision, the written notice will explain how you may request an administrative hearing about the report and its conclusions per Iowa Code sections 235A.19 or 235B.10.