Form Msc 301 Qed - Background Check Request Form

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SHARED SERVICES
Background Check Unit
BACKGROUND CHECK REQUEST (301QED)
his form is to be used to assist in gathering information to be entered into the
T
CRIMS system.
The instructions for the Qualified Entity Designee (QED) are available separately in form
MSC 301QED-Instructions.
The instructions for the Subject Individual (SI) are attached to this form and must be given to the SI.
Section 1 — To be completed by the QED or the Qualified Entity Initiator (QEI)
1. QED agency name:
QED agency street address:
QED agency City/State/ZIP code:
2. QED name:
QED phone number:
QEI name (if applicable):
QEI phone number:
3. Application type (select one program area for this position):
APD
DD
MH
PLA
CW
VR
If an ADP, is this application for a skilled position in a nursing facility only?
Yes
No
Is this position:
Paid (for example: employee or contractor)
Non-paid (for example: volunteer, household member in AFH, etc.)
4. Start date for position (mm/dd/yyyy):
Is this a recheck of the SI in the same position?
Yes
No
5. Position title:
Description of duties:
6. Position requires direct contact with (select all that apply):
Adults
Children
Seniors (65 years and older)
Confidential information
Secure facilities
Finances/financial records
Information technology systems
7. Do the duties require driving?
Yes
No
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MSC 301 QED (10/12)

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