Notic of Final Fitness Determinatiion - Volunteer

Administrative Services
Office of Human Resources
Background Check Unit /

Confidential Information

Notice of Final Fitness DeterminationCriminal Records Check and Abuse Check — DHS Volunteers

Original notice Amended notice
1. Name and mailing address of subject individual: / 2. Date of birth (mm/dd): / 3. SSN (last 4 digits):
4. Position/job title: / 5. Worksite location:

Final fitness determination. Abuse check: OAR 407-007-0400 — 407-007-0460
Criminal records check: OAR 407-007-0000 — 407-007-0100

This notice of fitness determination is the outcome an abuse check and criminal records check conducted on a individual who is seeking volunteer placement with the department including students and work experience positions at DHS sites.
If a subject individual has potentially disqualifying crimes or conditions or potentially disqualifying abuse, the department considered several factors in a “weighting test” to make fitness determination. See OAR 407-007-0040 to
407-007-0060 for criminal records checks.See OAR 407-007-0430 for abuse checks.

Approved on abuse check and criminal records check

Denied on abuse check(no criminal records check completed; no hearing rights allowed)

Approved with restrictions(hearing rights allowed)

List restriction:

Denied on criminal records check(hearing rights allowed)

Denial or restricted approval based on:

Potentially disqualifying crimes (OAR 407-007-0040):
Potentially disqualifying conditions (OAR 407-007-0050):

Case closed(no hearing rights allowed):

Denied or case closed individual cannot be employed or placed.
If you are approved with restrictions or denied, you may appeal. The request must be received by DHS—BCU within 45 daysfrom the effective date on this form.
Complete a Hearing Request ((DHS 0299HR) available at www.oregon.gov/DHS/chc/forms.shtml)and mail it with a copy of this notice to:DHS—BCU, HR Appeals, PO Box 14870, Salem, OR97309-5066.
If you do not request a hearing within the time allowed, you waive your right to a hearing. This notice of fitness determination becomes the final order in your case. If you request a hearing, but later withdraw the request or fail to appear at the contested case hearing, this notice becomes final as if you had never requested a hearing. You have the right to be represented by an attorney. Legal aid organizations may be able to assist you (ORS 183.415).
The hearing will be conducted in accordance with OAR 137-003-0501. See OAR 407-007-0080. If you believe your criminal or abuse record is incorrect, you must contact the agency that is the holder of the record. See instructions included with the DHS Criminal History Request Form (DHS 301HR).
For questions, or this form in large print or in different format,call DHS BCU tollfree at 1-888-272-5545.
7. Qualified entity: / 8. Authorized designee name:
Department of Human Services
500 SUMMER STREET NE
SALEM OR 97301
9. Signature: / Date signed:
10. Effective date of action:

DHS 0300HR-volunteer (10/09)