Missouri Department of Health & Senior Services Forms
Worker Registration Form
A person may register online by clicking Register Onlineor by mailing a completed Worker Registration Form, photocopy of their Social Security card and a $10.00 registration fee (if applicable) by check or money order, made payable to Missouri Department of Health and Senior Services. Registrants will receive written notification of their background screening results.
This form is in Microsoft Word format. Select 'Read-only' to open form. When all fields have been completed, please print form, sign and date before submitting to the Family Care Safety Registry
Employer Background Screening Request Form
Employers use this form to obtain background results at no charge. Employers may submit an Employer Background Screening form along with the Worker Registration form(s) being submitted on employees new to the Registry. Both the employer and employee will receive written notification of the background screening results.
An employer may FAX this form to 573-522-6981.
Employer Background Screening Request Form
Employer Background Screening Request Form
This form is in Microsoft Word format. Select 'Read-only' to open form. When all fields have been completed, please print form, sign and date before submitting to the Family Care Safety Registry.
Internet Access for Providers
Internet access for obtaining background screening results may be granted to a pre-approved provider in good standing with and licensed by or contracted with the Department of Health and Senior Services. Click How to Become A FCSR Internet User for more information.