Form Msc 0301ad - Background Check Request Form Page 3
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4Background Check Request
301 AD
Instructions for Subject Individual
Read all the instructions before completing the form.
As the subject of this background check, you are referred to in these instructions as the subject
individual (SI). The qualified entity (QE) listed in box 1 may be your employer or local branch. The
authorized designee (AD) or contact person (CP) has received training from the Department of
Human Services Background Check Unit (BCU) for background checks.
Section 1 through section 4: These sections will be completed by the QE or BCU.
Section 5: You, the subject individual, must complete section 5. Provide all requested information.
Listing your social security number (SSN) is optional. If you do not provide your SSN, fingerprints may
be required. If you do not have an SSN but do have an INS number, write in your INS number. BCU
requests the SSN or INS number solely for the purpose of positively identifying you during the
background check process.
Disclose all criminal history: You must accurately and completely disclose all history (adult and
juvenile) regardless of how long ago it happened. This includes all felonies, misdemeanors, probation
violations and failures to appear. If you fail to list any part of your history, your application may be
closed. Serious traffic offenses such as reckless driving, driving under the influence of intoxicants
(DUII) and driving while suspended (DWS) must be listed. Failure to appear, even for a minor traffic
violation must be listed. If you are not sure if something should be listed, you should list it. For each
charge, arrest or conviction, include the date, location and the outcome.
If you have proof that an expunction judgment or set aside order has been issued by a judge
regarding any charge, arrest, conviction, or adjudication, then you do not have to list it or you may
attach copies of the judgment or order. If you do not have proof the charge, arrest, conviction or
adjudication has been expunged or set aside, list it.
Violations. Minor moving and non-moving traffic violations are not required to be listed.
Questions to answer: 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.
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What happened leading up to the charge, arrest, conviction or other history?
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List any requirements resulting from each charge, arrest or conviction.
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Describe any treatment, education and training specifically related to your history.
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How is your history relevant to your position?
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Explain how you no longer pose a risk to the physical, emotional or financial well-being of
vulnerable people.
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How has your life changed since your history?
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List other information you believe would be helpful in making a decision in this case.
After completing Section 5, return the form to the person listed in section 1, box 1.
Page 3
MSC 0301AD (05/11)
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Parent category: Business