Written Authorization to Request a CAPS Check Please enable JavaScript in your browser to complete this form.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 an individual who may be employed or contracted to provide direct care to at-risk adults. An employer may also request a check for an eligible existing employee, volunteer, or CDASS provider.The CAPS check tells the authorized agency whether the individual has been substantiated in an APS case involving mistreatment of an at-risk adult, including physical abuse, sexual abuse, caretaker neglect, exploitation, or a harmful act. More information is in C.R.S. 26-3.1-111 and 12 CCR 2518-1.Written authorization is required before the check. Complete this form in full. Knowingly providing inaccurate information for a CAPS check is a class 2 misdemeanor under C.R.S. 26-3.1-111(6)(e.7).CAPS results are confidential and may be shared only with people involved in the employer’s hiring process, as permitted by law. A screening or staffing agency may share results with the employer it supports for a direct-care position.Agency information (completed by Craft Health)Agency name: Craft HealthAgency address: 5277 Manhattan Circle, Suite 100, Boulder, CO 80303Individual's InformationFull legal name: *FirstMiddleLastMaiden Name/Previous Name(s)/Alias:Date of Birth: *SSN (Last 4 digits): *DORA License # (required for all licensed professionals):Names of previous employers during the past five (5) years *List every employer during the past five years. If none, enter None.You must provide one (1) personal phone number and one (1) email address.Personal Email Address: *Individual's personal phone number including area code: *Provide at least five (5) consecutive years of residential history, including time outside the United States. For international addresses, include the city and country. If your current address does not cover five consecutive years, list each previous address and its start and end dates. Upload an additional sheet if needed.Current Address Start Date: *Current Street and Number (No PO boxes): *Current Address City: *Current State: *Current Zip/Postal Code: *Previous Address 1 Date (City professionals): Previous 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. Drag & Drop Files, Choose Files to Upload Parent or guardian (only if signing for a minor applicant)I am the parent or guardian completing this form for a minor child seeking employment.Authorization and declarationI authorize Craft Health to request a CAPS check to determine whether I have a substantiated finding of mistreatment of an at-risk adult. If a screening or staffing agency requests the check for Craft Health, I understand the result may be shared with Craft Health.I acknowledge that a substantiated finding, unless expunged through a successful appeal, will be provided only to people directly involved in the hiring process and may inform the hiring decision. CAPS may notify Craft Health of future substantiated findings during my employment or assignment.I understand that knowingly providing inaccurate information on this authorization for a CAPS check is a class 2 misdemeanor under C.R.S. 26-3.1-111(6)(e.7). Under penalty of perjury under Colorado law, I declare that this authorization and any supporting documents are true, correct, and complete. If I selected the parent or guardian box, I make these statements on the minor applicant’s behalf.By typing my full legal name below and selecting Submit, I electronically sign this authorization.Electronic signature — type your full legal name *Date * Submit