CFS 718-1, Authorization for Background Check Instructions

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This form contains 121 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Age
Age Text
Please enter the current age of the individual.
Cell Phone
Cell Phone Area Code Text
Please provide the area code of your cell phone number.
Max length: 3 characters
Cell Phone Prefix Text
Please provide the prefix of your cell phone number.
Max length: 3 characters
Cell Phone Line Number Text
Please provide the line number of your cell phone number.
Max length: 4 characters
Child Abuse/Neglect Investigation Question
Yes Checkbox
Check this box if you have ever been indicated as a perpetrator in a child abuse/neglect investigation.
No Checkbox
Check this box if you have never been indicated as a perpetrator in a child abuse/neglect investigation.
Citizenship
USA Checkbox
Check this box if your citizenship is USA.
Other (Specify) Checkbox
Check this box if your citizenship is not USA, and specify the country in the provided space.
Other Citizenship Country Text
Please specify the country of your citizenship if it is not USA. Fill only if 'Other (Specify)' is 'Yes'.
Depends on: Other (Specify)
Criminal Offense Question
Yes Checkbox
Check this box if you have ever been convicted of a criminal offense, other than a minor traffic violation.
No Checkbox
Check this box if you have never been convicted of a criminal offense, other than a minor traffic violation.
Current Address
Street Address and Apartment Number Text
Provide the street address and apartment number for the current residence.
City Text
Enter the city of the current residence.
State Text
Enter the state of the current residence.
Max length: 2 characters
Zip Code Text
Provide the postal zip code for the current residence.
Max length: 5 characters
County Text
Enter the county of the current residence.
Date of Birth
Birth Month Text
Please enter the month of birth.
Max length: 2 characters
Birth Day Text
Please enter the day of birth.
Max length: 2 characters
Birth Year Text
Please enter the year of birth.
Max length: 4 characters
Ethnicity
Ethnicity Code Text
Provide the numerical code that represents your ethnicity, which can be found by referring to the codes listed on Page 2 of this form.
Facility Type and Person (Row A)
Day Care Home Checkbox
Check this box if the specific type of application is for a Day Care Home.
Group Day Care Home Checkbox
Check this box if the specific type of application is for a Group Day Care Home.
Applicant Checkbox
Check this box if the person in the home or facility is the applicant. Fill only if 'Day Care Home', 'Group Day Care Home' is 'Yes', any.
Depends on: Day Care Home, Group Day Care Home
Member of Household (age 13 and over) Checkbox
Check this box if the person in the home or facility is a household member aged 13 or over. Fill only if 'Day Care Home', 'Group Day Care Home' is 'Yes', any.
Depends on: Day Care Home, Group Day Care Home
Employee/Volunteer (includes household member under age 18 who is also an employee/volunteer) Checkbox
Check this box if the person in the home or facility is an employee or volunteer, including household members under 18 who are also employees or volunteers. Fill only if 'Day Care Home', 'Group Day Care Home' is 'Yes', any.
Depends on: Day Care Home, Group Day Care Home
Facility Type and Person (Row B)
Day Care Center Checkbox
Check this box if the facility type is a Day Care Center.
Day Care Agency Checkbox
Check this box if the facility type is a Day Care Agency.
Applicant/Operator/Owner Checkbox
Check this box if the person is an Applicant, Operator, or Owner in the facility. Fill only if 'Day Care Center', 'Day Care Agency' is 'Yes', any.
Depends on: Day Care Center, Day Care Agency
Executive Director/Day Care Center Director Checkbox
Check this box if the person is an Executive Director or Day Care Center Director in the facility. Fill only if 'Day Care Center', 'Day Care Agency' is 'Yes', any.
Depends on: Day Care Center, Day Care Agency
Employee/Volunteer Checkbox
Check this box if the person is an Employee or Volunteer in the facility. Fill only if 'Day Care Center', 'Day Care Agency' is 'Yes', any.
Depends on: Day Care Center, Day Care Agency
Fifth Past Address
Fifth Past Address Details Text
Provide the complete street address, apartment number, city, state, and zip code for the fifth past address where you resided. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Fifth Past Address Dates Text
Enter the 'From' and 'To' dates indicating the period you resided at this fifth past address. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
First Past Address
Past Address Details Text
Please provide the complete street address, apartment number, city, state, and zip code for this past address. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Dates of Occupancy Text
Please provide the start and end dates for when you resided at this past address. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Fourth Past Address
Fourth Past Address Text
Enter the complete street address, apartment number, city, state, and zip code for the fourth past address you have resided at. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Fourth Past Address Dates From To Date
Enter the start and end dates for the period you resided at the fourth past address. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Full Name
Last Name Text
Please enter the last name of the individual.
First Name Text
Please enter the first name of the individual.
Middle Initial Text
Please enter the middle initial of the individual.
General
Text22 Text
Max length: 1 characters
Text23 Text
Max length: 1 characters
Text24 Text
Max length: 1 characters
Text25 Text
Max length: 1 characters
Text26 Text
Max length: 1 characters
Text27 Text
Max length: 1 characters
Text28 Text
Max length: 1 characters
Text30 Text
Max length: 1 characters
Text31 Text
Max length: 1 characters
Text32 Text
Max length: 1 characters
Text33 Text
Max length: 1 characters
Text34 Text
Max length: 1 characters
Text35 Text
Max length: 1 characters
Text36 Text
Max length: 1 characters
Text37 Text
Max length: 1 characters
Text38 Text
Max length: 1 characters
Text39 Text
Max length: 1 characters
Text40 Text
Max length: 1 characters
Text41 Text
Max length: 1 characters
Text42 Text
Max length: 1 characters
Text43 Text
Max length: 1 characters
Text44 Text
Max length: 1 characters
Text45 Text
Max length: 1 characters
Text46 Text
Max length: 1 characters
Text47 Text
Max length: 1 characters
Text48 Text
Max length: 1 characters
Text49 Text
Max length: 1 characters
Text50 Text
Max length: 1 characters
Text51 Text
Max length: 1 characters
Text52 Text
Max length: 1 characters
Text53 Text
Max length: 1 characters
Text54 Text
Max length: 1 characters
Text55 Text
Max length: 1 characters
Text56 Text
Max length: 1 characters
Text57 Text
Max length: 1 characters
Text58 Text
Max length: 1 characters
Text106 Text
Text107 Text
Text108 Text
Text109 Text
Printed Full Name Line 1 Text
Please print the first line of your last name, first name, and middle initial.
Printed Full Name Line 2 Text
Please print the second line of your last name, first name, and middle initial if the name does not fit on the first line.
Printed Full Name Line 3 Text
Please print the third line of your last name, first name, and middle initial if the name does not fit on the previous lines.
Provider ID Text
Please enter your unique Provider ID.
Home Telephone
Home Telephone Area Code Text
Provide the three-digit area code for the home telephone number.
Max length: 3 characters
Home Telephone Prefix Text
Provide the three-digit prefix for the home telephone number.
Max length: 3 characters
Home Telephone Line Number Text
Provide the four-digit line number for the home telephone number.
Max length: 4 characters
Illinois Residence Question
Yes Checkbox
Check this box if you have lived outside of Illinois at any point in the past five years.
No Checkbox
Check this box if you have continuously lived within Illinois for the entire past five years.
Maiden or Formerly Used Names
Maiden or Formerly Used Name 1 Text
Provide the first maiden or formerly used name, including last name, first name, and middle initial.
Maiden or Formerly Used Name 2 Text
Provide the second maiden or formerly used name, including last name, first name, and middle initial.
Physical Description
Height (Feet) Text
Enter the person's height in feet.
Weight (Pounds) Number
Enter the person's weight in pounds.
Hair Color Text
Enter the person's hair color.
Eye Color Text
Enter the person's eye color.
Place of Birth
Place of Birth Text
Please enter the city and state where you were born.
Printed Full Name
Text106 Text
Text107 Text
Text108 Text
Printed Last Name Text
Enter your last name as it should be printed on the form.
Printed First Name and Middle Initial Text
Enter your first name and middle initial as they should be printed on the form.
Text108 Text
Provider ID
Text109 Text
Provider ID Text
Enter the provider identification number.
Race and Tribal Affiliation
Native American/Alaskan (Indian or Eskimo) Checkbox
Check this box if the individual identifies as Native American or Alaskan (Indian or Eskimo).
Tribal Affiliation Yes Checkbox
Check this box if the individual has a tribal affiliation. Fill only if 'Native American/Alaskan (Indian or Eskimo)' is 'Yes'.
Depends on: Native American/Alaskan (Indian or Eskimo)
Tribal Affiliation No Checkbox
Check this box if the individual does not have a tribal affiliation. Fill only if 'Native American/Alaskan (Indian or Eskimo)' is 'Yes'.
Depends on: Native American/Alaskan (Indian or Eskimo)
Black/African American Checkbox
Check this box if the individual identifies as Black or African American.
Native Hawaiian/Pacific Islander Checkbox
Check this box if the individual identifies as Native Hawaiian or Pacific Islander.
Asian Checkbox
Check this box if the individual identifies as Asian.
White Checkbox
Check this box if the individual identifies as White.
Unknown Race Checkbox
Check this box if the individual's race is unknown.
Declined to Identify Race Checkbox
Check this box if the individual declines to identify their race.
Race Could Not Be Verified Checkbox
Check this box if the individual's race could not be verified.
Second Past Address
Second Past Address Text
Enter the complete second past address, including street, apartment number, city, state, and zip code. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Past Address Dates Date
Enter the start and end dates for when you resided at the second past address. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Sex
M Checkbox
Check this box if the individual's sex is male.
F Checkbox
Check this box if the individual's sex is female.
Social Security or ITIN Number
Social Security or ITIN Prefix Text
Please enter the first three digits of your Social Security or ITIN number.
Max length: 5 characters
Social Security or ITIN Suffix Text
Please enter the remaining six digits of your Social Security or ITIN number.
Max length: 4 characters
Third Past Address
Third Past Address Text
Provide the complete street address, apartment number, city, state, and zip code for this past address. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Third Past Address Dates From To Text
Enter the 'From' and 'To' dates indicating the period you lived at this past address. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes