Form 2405, Affidavit for Risk Evaluation by Child Placing Agency

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Effective Date: 1/2019



Updated 1/2019



Child Placing Agencies regulated by Child Care Licensing use this form to provide a rationale for a person who requires a risk evaluation:

  • whose criminal history or Central Registry history is a violation of minimum standards that is eligible for a risk evaluation; and
  • whom the operation would like to continue to pursue association (such as employment, verification or volunteerism) with their operation.


Fill out this form in its entirety. After completing the form, submit it to your Centralized Background Check Unit (CBCU) representative by the due date provided to your operation. If you are unsure who your CBCU representative is, contact your Child Care Licensing representative for more information.

Once CBCU receives and processes all required documentation, CBCU will send you a letter notifying you whether the person is eligible, eligible with conditions, or denied. An approved or conditionally approved risk evaluation is specific to a particular role. If a person has an approved or conditionally approved risk evaluation and the person’s role changes, the risk evaluation is no longer valid and a new risk evaluation must be completed.