Office of Human Resources — Background Check Unit
Background Check Request
Section 1: Completed by AD — Type or print clearly
2. AD phone:
1. All items are required:
AD name; QE name; street address; city, state, ZIP code
3. SI start date:
Change in position
Or recheck due to:
In this position, SI is:
Paid directly or indirectly with public funds
Not paid/reimbursed or only privately paid
5. Contact with:
4. SI job title:
6. Do the duties include driving?
Description of duties:
7. DHS/OHA program area: (Check all that apply.)
Worksite and address:
Section 2: Preliminary review — Completed by AD/CP
8. Name of subject individual: (last, first, middle)
Social Security or INS number: (voluntary)
9. Type of ID(s) checked: (driver’s license, passport, etc.)
QE staff signature:
10. Fingerprints required?
If yes, check all reasons that apply and mail (do not FAX) this form with the fingerprints.
Out-of-state driver’s license
No potentially disqualifying history disclosed.
Hired on a preliminary basis:
Potentially disqualifying history disclosed.
Hired on a preliminary basis (by AD only):
If so, attach position description.
Section 3: Background check information — For BCU use only
Potentially disqualifying convictions or conditions.
Disposition unknown. Consult SI about arrests/charges.
Section 4: Final fitness determination —
ORS 181.537; OAR 407-007-0200 to 407-007-0370.
NOTE: FOR APPROVALS ONLY, provide the SI a copy of this page as the formal and final notice for the position and worksite
listed in box 4. IN ALL OTHER CASES, if BCU completes this section, BCU will issue the final notice to the SI. Otherwise, you
must complete this section and issue either a Notice of Final Fitness Determination (300) or a Notice of Closed Case (302).
Approved with restrictions:
AD or BCU Signature:
See AD/CP instructions. Mail with fingerprints if prints required. FAX or mail (not both) only pages 1 and 2 of this form.
MSC 0301AD (05/11)