Form Msc 301 Qed - Background Check Request Form (Page 6 of 7) in pdf

should list it. For each charge, arrest or conviction, include the exact date (mm/dd/yyyy),

location and the outcome.

If you do not have proof the charge, arrest, conviction or adjudication has been expunged or set

aside then list it.

Violations. Minor moving and non-moving traffic violations are not required to be listed.

If you have criminal history, BCU will weigh several factors to decide if you are fit for the

position for which you are applying. Respond to the following questions. Attach

documentation to support your responses.

What happened leading up to the charge, arrest, conviction or other history?

List any requirements resulting from each charge, arrest or conviction.

Describe any treatment, education and training specifically related to your history.

How is your history relevant to your position?

Explain how you no longer pose a risk to the physical, emotional or financial well-being

of vulnerable people.

How has your life changed since your history?

List other information you believe would be helpful in making a decision in this case.

22.

Sign and date the form. Return it to the person listed in #2.

Possible outcome of your background check:

Approved: Your background check is approved for the position listed on this form. An

approval does not guarantee employment or placement.

Approved with restrictions: Your background check is approved to work but are

restricted to a specific client, a specific work site or a set of duties. This decision may be

appealed. A restricted approval does not guarantee employment or placement.

Denial: Based on the background check, you are denied. You may not hold the position

listed on this form and you must be terminated immediately. This decision may be

appealed, but you may not hold the position during the appeal.

Case closed: If you do not provide a complete and accurate disclosure of your criminal

history or you do not cooperate with this background check process, your application

may be closed without a final decision. There are no appeal rights, but you

may be able to reapply immediately. If closed, the department will provide you with

further information.

Ineligible: Due to ORS (Oregon Revised Statute), 443.004, prohibits individuals from

working in certain positions if they have one or more specific convictions. If found

ineligible, you may not hold the position listed on this form and must be terminated

immediately. You do not have hearing rights. The BCU will provide more information in

the email or letter sent to you.

Abuse checks — BCU will also conduct an abuse check on you. Potentially disqualifying abuse

includes the following:

For ALL subject individuals: Adult protective services history of physical or sexual

abuse or financial exploitation assessed on or after January 1, 2010 for which you

were found to be responsible. Abuse information is provided to BCU by the Office

of Abuse Prevention and Investigations and the Aging and People with Disabilities

(APD) based on severity.

Page 6 of 7

MSC 301 QED (10/12)

Form Msc 301 Qed - Background Check Request Form Page 6

Related Articles

Related forms

Related Categories