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Welcome to the New York Citizen Teacher Background Check Form!
Information collected in the following section will be used to determine whether or not you are subject to an indicated report of child abuse and maltreatment. The background check will be run by the New York State Statewide Central Registry online database. All the information you provide will be stored in a secure database.
Contact Information

If any of the auto-filled information below is inaccurate, please correct it here.















This information will be used to determine if you are listed on the register of substantiated category one cases of abuse or neglect maintained by the Justice Center for the Protection of Persons with Special Needs.

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Information collected in the following section will be used to determine whether or not you are subject to an indicated report of child abuse and maltreatment.  The background check will be run by the New York State Statewide Central Registry online database.
Household Members


Please list all individuals currently residing with you at your current address.  (Repeat until all household members are listed.)





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Information collected in the following section will be used to determine whether or not you are subject to an indicated report of child abuse and maltreatment.  The background check will be run by the New York State Statewide Central Registry online database.
Your Addresses

Please provide all addresses in which you have resided for the last 28 years, or since birth if you are under 28. Please note that Post Office Boxes will not be accepted. Work backwards from your current address. Make sure all dates are consecutive (there should be no gaps in dates). For example, if you lived in your last address from 02/2005 to 02/2012, the address you list next should include 02/2005 as the date for "When did you stop living at the residence?"

Current Address

Previous Addresses









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Please provide three references, two of which must be employment references.
References may be contacted to verify your employment history, work record, personal and professional qualifications, character, and habits.

Personal Reference
Must know for a minimum 2 years, cannot be a relative.












Employment References
Must know for a minimum 1 year, cannot be a relative.
























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Please attach a copy of your resume. This meets the NY State Office of Children and Family Services background check requirement of a statement or summary of each applicant's employment history including, but not limited to, any relevant child-caring experience.

THANK YOU for completing this background check form!
Visit the clearance website to complete all remaining steps: medical, fingerprinting, and online training.

A Citizen Schools staff member will contact you if we have any questions.