Background Check Authorization Form

PROCESSING CODE
Background Check Authorization
SECTION 1. ENTITY INFORMATION (COMPLETED BY DSHS STAFF, PROVIDER, APPLICANT, LICENSEE, AND/OR CONTRACTOR)
1A. ENTITY REQUESTING THE BACKGROUND CHECK 1B. ENTIRE ADDRESS OF ENTITY LISTED IN BOX 1A 1C. NAME OF SECONDARY ENTITY
2.
3.
REQUIRED: NAME AND SIGNATURE OF PERSON REQUESTING THE BACKGROUND CHECK
PRINTED NAME:
SIGNATURE:
REQUIRED ONLY FOR DSHS STATE EMPLOYMENT
DSHS POSITION NUMBER (WRITE NONE IF NONE) DSHS JOB CLASSIFICATION: PERSONNEL IDENTIFICATION NUMBER:
Permanent appointment Non-permanent appointment Work study / student internship Volunteer Acting
4. REQUIRED: BCCU ACCOUNT NUMBER
5. DSHS ID NUMBER OR NAME
SECTION 2. THIS SECTION IS FOR APPLICANT INFORMATION ONLY (THE PERSON TO BE CHECKED IS THE APPLICANT)
6. SOCIAL SECURITY NUMBER
7. REQUIRED: DATE OF BIRTH (MM/DD/YYYY)
8. PRINT YOUR E-MAIL ADDRESS
9. REQUIRED: PRINT YOUR NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR OTHER PHOTO ID. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER.
FIRST: MIDDLE: LAST:
10. REQUIRED: PRINT ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER.
FIRST: MIDDLE:
LAST:
REQUIRED: SELF DISCLOSURE QUESTIONS. SEE INSTRUCTIONS.
You must answer Questions 11A through 14. Attach an additional sheet of paper if you need to list additional crimes or pending charges.
11A. Have you been convicted of any crime? If yes, fill in the blanks below. .......................................................................................... Yes No
Degree:
11B. Do you have charges (pending) against you for any crime? If yes, fill in the blanks below. ............................................................ Yes No
Degree:
State: Conviction date: / /
State:
12. Has a court or state agency ever issued you an order or other final notification stating that you have sexually
abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult? ............................................. Yes No
13. Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for
children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government
agency was taking action against you for failing to care for children, juveniles, or vulnerable adults? .................................................... Yes No
14. Has a court ever entered any of the following against you for abuse, sexual abuse, neglect, abandonment,
domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile or child? ............................................................ Yes No
Permanent* vulnerable adult protection order / restraining order, either active or expired, under RCW 74.34.
Sexual assault protection order under RCW 7.90.
Permanent* civil anti-harassment protection order, either active or expired, under RCW 10.14.
See instructions for description of “permanent.”
15. REQUIRED: PRINT YOUR DRIVER’S LICENSE OR STATE IDENTIFICATION NUMBER (WRITE NONE IF NONE) REQUIRED: PRINT THE NAME OF THE STATE ON YOUR LICENSE OR ID
16. REQUIRED
Have you lived in any state or country other than Washington State within the last three years (36 months)? Yes No
17. A. REQUIRED: PRINT YOUR MAILING ADDRESS WHERE WE CAN SEND YOU CONFIDENTIAL INFORMATION
CITY
B. REQUIRED: PRINT THE STREET ADDRESS WHERE YOU LIVE NOW (WRITE “SAME” IF YOUR STREET ADDRESS IS THE SAME AS YOUR MAILING ADDRESS)
CITY
C. REQUIRED: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED
APT. NO.
STATE
ZIP CODE
APT. NO.
STATE
ZIP CODE
18. I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to
work with vulnerable adults, juveniles or children. I understand and agree my signature in box number 19 means:
I give DSHS permission to check my background with any governmental entity and law enforcement agency.
My background check result may include prior self-disclosure information and fingerprint results that are contained in the DSHS Background
Check System and that this information will be reported as allowed by federal or state law.
If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result.
DSHS will give my background check result to the persons or entities named in Section 1 and may release my background check results to other
persons or entities when the law authorizes or requires DSHS to do so. Fingerprint rap sheets are provided if allowed by federal or state law.
The entity requesting this background check must submit this form to the Background Check Central Unit within the timeframe required by the
DSHS oversight program.
19. REQUIRED: YOUR SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18.
20. REQUIRED: TODAY’S DATE (MM/DD/YYYY)
PROGRAM USE – FOLLOW INSTRUCTIONS PROVIDED BY YOUR DSHS OVERSIGHT PROGRAM
DSHS 09-653 (REV. 04/2015)
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