Written Authorization to Request a CAPS Check Please enable JavaScript in your browser to complete this form. A check of the Colorado Adult Protective Services (APS) data system (CAPS) is required for you (individual) because you are: A potential employee/contractor who will provide direct care to at-risk adults. An employer may also request a CAPS check for you if you provide direct care to an at-risk adult and you: Were hired/contracted prior to the CAPS check requirement (1/1/2019), or Are a volunteer, or Will provide services to a CDASS recipient The CAPS check will alert the employer (agency) whether you have or have not be substantiated in an APS case of mistreating an at-risk adult, to include physical abuse, sexual abuse, caretaker neglect, exploitation, and/or harmful act. More information on the CAPS check requirement can be found in Colorado Revised Statute (26-3.1-111, C.R.S.) and in the Colorado Code of Regulations (12 CCR 2518-01). Written authorization is required from the individual being checked, using this form. Please complete this form in its entirety. Knowingly providing inaccurate information on a CAPS check request is a class 1 misdemeanor pursuant to 18-1.3-501, C.R.S. Agency Name: Craft Health Agency Address: 1650 38th Street, Suite 101E, Boulder, CO 80301Individual's InformationName (Please enter full name): *FirstMiddleLastMaiden Name/Previous Name(s)/Alias:Date of Birth: *SSN (Last 4 digits): *DORA License # (required for all licensed professionals):Provide the Name(s) of Your Previous Employer(s) Over the Past Five (5) Years: *You must provide at least one (1) personal phone number and one (1) email address.Personal Email Address: *Work Email Address:Cell Phone: *Home Phone:Work Phone:Work Phone Extension:All individuals are required to provide five (5) years of residential history, regardless of whether in the U.S. or abroad. If you lived outside of the US in the past five (5) years, provide the international address(es), including the name of the city and country. If you have lived at your current address less than 5 years, please list your previous addresses for the past five years. Use another sheet of paper if necessary.Current Address Start Date: *Current Street and Number (No PO boxes): *Current Address City: *Current State: *Current Zip/Postal Code: *Previous Address 1Previous Address Start Date:Previous Address End Date:Previous Street and Number (No PO Boxes):Previous City (City and country for international addresses):Previous State (Not required for international addresses):Previous Zip Code (Use "00000" for international addresses):Previous Address 2Previous Address Start Date:Previous Address End Date:Previous Street and Number (No PO Boxes):Previous City (City and country for international addresses):Previous State (Not required for international addresses):Previous Zip Code (Use "00000" for international addresses):Previous Address 3Previous Address Start Date:Previous Address End Date:Previous Street and Number (No PO Boxes):Previous City (City and country for international addresses):Previous State (Not required for international addresses):Previous Zip Code (Use "00000" for international addresses):Previous Address 4Previous Address Start Date:Previous Address End Date:Previous Street and Number (No PO Boxes):Previous City (City and country for international addresses):Previous State (Not required for international addresses):Previous Zip Code (Use "00000" for international addresses):Upload any additional sheets, if necessary. Click or drag a file to this area to upload. I understand by typing my name and clicking on "Submit," I am electronically signing this document and authorize the employer referenced above to request a CAPS check to determine if I have a substantiated finding as a perpetrator of mistreatment of an at-risk adult. I acknowledge that a substantiated finding resulting from such a check, unless the finding was expunged through a successful appeal, shall be provided to the person directly involved in the employer's hiring process and may be used to inform their hiring decision of me. I acknowledge notification may occur through CAPS to this employer, for the duration of my employment or volunteer assignment with them, of any future substantiated findings against me. I understand that willfully providing false information on this form is a misdemeanor 1 penalty, punishable as outlined in ยง18-1.3-501, C.R.S. I declare under penalty of perjury under Colorado Law that this CAPS Check Request Form, including supporting documents, has been examined by me and is true, correct, and complete. *Date * Submit