Form Msc 0301ad - Background Check Request Form
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Office of Human Resources — Background Check Unit
Background Check Request
301 AD
Confidential
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:
New hire/rehire
Change in position
Or recheck due to:
Program rules
Other:
In this position, SI is:
Paid directly or indirectly with public funds
Not paid/reimbursed or only privately paid
5. Contact with:
Children
Adults
Seniors
4. SI job title:
6. Do the duties include driving?
Yes
No
Description of duties:
7. DHS/OHA program area: (Check all that apply.)
Developmental disability
Senior AAA
Child Welfare
Senior branches
Worksite and address:
Mental health
Senior facilities
Lifespan respite
Vocational rehabilitation
Section 2: Preliminary review — Completed by AD/CP
8. Name of subject individual: (last, first, middle)
DOB: (mm/dd/yy)
Social Security or INS number: (voluntary)
9. Type of ID(s) checked: (driver’s license, passport, etc.)
QE staff signature:
Date:
10. Fingerprints required?
No
Yes
If yes, check all reasons that apply and mail (do not FAX) this form with the fingerprints.
Residency
Identity
Out-of-state driver’s license
Out-of-state history
Adam Walsh
11.
No potentially disqualifying history disclosed.
Hired on a preliminary basis:
Yes
No
AD/CP signature:
Date:
12.
Potentially disqualifying history disclosed.
Hired on a preliminary basis (by AD only):
Yes
No
If so, attach position description.
AD signature:
Date:
Section 3: Background check information — For BCU use only
LEDS/abuse:
Reviewer:
13.
Yes
No
Potentially disqualifying convictions or conditions.
Disposition unknown. Consult SI about arrests/charges.
Date:
Date:
DL:
AKAs:
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).
14.
Approved
Approved with restrictions:
Denied
Case closed:
AD or BCU Signature:
Date:
See AD/CP instructions. Mail with fingerprints if prints required. FAX or mail (not both) only pages 1 and 2 of this form.
Page 1
MSC 0301AD (05/11)
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Parent category: Business