Background Authorization - Washington State Department Of Early Learning (Page 2 of 4) in pdf

11. Have you been convicted of any crime or had any other disposition of criminal charges against you in any local, state, federal, military

(either through judicial or non-judicial means), tribal or foreign jurisdiction? For the purposes of this question “crime” means a felony, a gross

misdemeanor, or a misdemeanor.

Yes

No (REQUIRED) If yes, fill in the blanks below; add a page if you need more room.

Crime:

Jurisdiction:

Decision:

Decision Date:

Crime:

Jurisdiction:

Decision:

Decision Date:

12. Do you have any criminal charges pending against you for any crime in any local, state, federal, military, tribal or foreign jurisdiction?

For the purposes of this question “crime” means a felony, a gross misdemeanor, or a misdemeanor. (REQUIRED)

Yes

If yes, fill in the blanks below; add a page if you need more room.

Crime:

Jurisdiction:

Degree:

Charge Date:

Crime:

Jurisdiction:

Degree:

Charge Date:

In any local, state, federal, military, tribal or foreign jurisdiction: (REQUIRED)

13. Have you ever received a notice or order from a court or government agency stating that you have or may have physically abused,

sexually abused, neglected, abandoned, or exploited a child, juvenile or vulnerable adult .....................................................

Yes

14. Has a court ever issued a restraining order, an order of protection, no contact order, or similar order against you for physically abusing,

sexually abusing, neglecting, abandoning, exploiting, harassing, or committing domestic violence against a child, juvenile or adult

(including but not limited to a vulnerable adult)?.......……………………………….………………..………….…………………….

Yes

15. Has any court ever found you to be in violation of a restraining order, order of protection, or no contact order, or similar

order?..........................................................................................................................................................................................

Yes

16. Have you ever been disqualified based on a background check from having unsupervised access to children, juveniles or vulnerable

adults? ……………………………………………………………………………………………………….…………………..………….

Yes

17. Has a government agency (including, but not limited to, a professional disciplinary board) ever notified you that an adverse finding or

decision was made against you or that adverse action was taken against you:

 .... With regard to a professional, business, or occupational license or certification. This includes, but is not limited to, the

revocation, denial, and suspension of a license, the assessment of civil penalties, and/or restrictions on practice, to include

being required to operate under the supervision of another person

Yes

 .... With regard to a contract. This includes, but is not limited to the denial, termination, or suspension of a contract.

Yes

18. Have you ever voluntarily surrendered a professional, business, occupational license or certification or a contract in lieu of adverse action

by a court or government agency? .............................................................................................................................................

Yes

19. I declare under penalty of perjury under the laws of the State of Washington that all information provided on this form is true and correct.

I understand that if the information I provided is determined not to be true and correct I may be charged with perjury, I may be disqualified

from having unsupervised access to children in care, and, if I am a child care licensee, DEL may revoke my license or take other

enforcement action against me. In addition, my signature in box 20 means:

a) I give DEL and DSHS permission to check my background with any government entity, including but not limited to law enforcement

agencies.

b) I give any governmental entity, including but not limited to law enforcement agencies, permission to release to DEL and DSHS any

background check information that DEL and DSHS requests.

c) In the event my background check information becomes pertinent to an appeal of a background check disqualification or a licensing

action, I give DEL and DSHS permission to release my background check information to an administrative law judge, and

administrative law review judge, or to a court.

d) I give DEL and DSHS permission to release my background check information as required by court order, the Public Disclosure Act,

Chapter 42.56 RCW, or other laws pertaining to privacy, confidentiality, or the release of public records.

e) I give DEL permission to give my background information to the person or entity named in Section 2.

These permissions are not time-limited.

21. Your Parent or Guardian’s Signature (REQUIRED) If you are less

20. Your Signature (REQUIRED)

than 18 years of age

23.Today’s Date (REQUIRED)

22. Please indicate where this form was signed

(Example: Name of city or county)

RETURN THE FORM TO THE LOCAL DEL OFFICE

10.9.2.1 Background Check Form

Rev. 8/11

Background Authorization - Washington State Department Of Early Learning Page 2

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