R-22a Child Protection Policy Compliance Verification Form (State/Metro)

This form must be submitted annually to USA Ministries by April 15.
An acknowledgement and a copy of this completed form will be sent to the state board chairman and the state director.  The document must be retained permanently in the state office files.
 
The following areas have been fully instituted for all paid staff, committee/board members and volunteers who have contact with minors under the ministry of this state/metro area. All have been fully screened according to the Child Protection Policy of USA Ministries. Complete the following checklist:
Received a completed employment application form (paid staff only). *
 
Received a completed Confidential Screening Form. *
 
Received a completed request for Background/Reference Check Authorization. *
 
Conducted a personal interview. *
 
Protecting Today's Child presentation viewed or listened to. *
 
Child Protection Policy read. *
 
Checked personal and church references on Confidential Screening Form (paid staff, camp and overnight volunteers only). *
 
Conducted a background check through appropriate agency. *
 
Minimum requirements for background check:
National Criminal Database Search *
 
National Sex Offender Registry Search *
 
SSN Address History Trace *
 
State check for all addresses in past five years (paid staff only) *
 
If your government jurisdiction requires more, you must also comply with their requirements. *
 
 +
(NOTE: On electronic forms, your typed signature carries the same weight as your written signature.)