Form Msc 0301ad - Background Check Request Form Page 4

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Approved: Based on the background check, you are approved for the position listed on this form.
An approval does not guarantee employment or placement.
Approved with restrictions: Based on the background check, you are approved to work
restricted to a specific client, specific work site or set of duties. This decision may be appealed.
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 fitness determination. There are no appeal rights, but you may be able to reapply
immediately. If closed, the department will provide you further information.
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 Investigation and Training and the Seniors and People with
Disabilities Division based on severity.
In addition, for subject individuals associated with private licensed child caring agencies, child foster
homes, or child adoptive homes: Child protective services history held by the department, regardless of the
date of assessment or outcome, for which you were found to be responsible; and founded or substantiated
child protective services reports from states where you lived in the past 5 years.
If potentially disqualifying abuse is found, you will be contacted and asked to provide additional information. Due
to its sensitive nature, the information you provide will not be disclosed to your potential employer or local
authorized designee or contact person.
Authority:
BCU is authorized by state law, to complete background checks on SIs who work, volunteer or live
with individuals who are vulnerable to abuse or mistreatment (ORS 181.534, 181.537 and 409.027; OAR 407-
007-0200 to 407-007-0370). Vulnerable individuals include children, senior citizens and individuals with physical
disabilities, developmental disabilities or mental illness. A check may be required even if you, the subject
individual, do not have direct contact with vulnerable individuals.
Sources checked:
BCU may check information from the Driver and Motor Vehicle Services Division;
Department of Corrections; Oregon State Police; Federal Bureau of Investigation and local, state and federal
courts. BCU may use information from other criminal justice, corrections and law-enforcement agencies and
other state and local government agencies. You may be requested to provide fingerprints for a national criminal
records check.
Challenging criminal information:
If you want to obtain a copy of your record or challenge information in the
record, you must contact the Oregon State Police, 503-378-3070, extension 330 (for Oregon criminal records) or
the Federal Bureau of Investigation, 304-625-3878 (for national criminal records). You may request a copy of the
national FBI report from BCU. Depending on your previous contacts with law enforcement and courts, you may
need to contact several sources to find all of your complete criminal records.
Rechecks:
This background check process may be repeated at any time while you work, reside or otherwise
continue in this position.
If you have questions or need this form in large print or in a different format, contact the qualified entity listed in
section 1, box 1.
Keep these instructions for your records.
Page 4
MSC 0301AD (05/11)

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