1
Page /Read all instructions before completing form
/ DHS 0301 (9/14/04)Criminal Records Unit (CRU) /
Criminal History Request
/CONFIDENTIALINFORMATION
Section 1: Completed by AD or contact person / 1Name of AD or CP, qualified entity and mailing address / 2 Type or location of positionCAFDHS-HRHSSPD
No authorized designee; CRU decision requested
Type or print clearly
A&DAdult FH
ALF
Child care
Child FH
DD
DHS employee / DHS volunteer
Home care worker
Mental health
Nursing facility
Personal care asst.
Private lic. agency / RCF/RTF
RCH/RTH
Staffing agency
System of care (CW)
Work experience
Other:
3 AD/CP name / AD
CP / 4 AD/CP phone / 5 SI Position/reason for check (e.g., job title) / 6 SI start date
7 SI position status (check each box that applies to this position): / 8 SI supervisor, worksite location, phone number
Contact with children
Contact with elderly
Contact with MH
Contact with DD / Involves driving
Care of relative
Contact with people with physical disability / Volunteer
Paid
Permanent
Temporary / Optional for non-DHS organizations.
1
Page /Read all instructions before completing form
/ DHS 0301 (9/14/04)Print Clearly / Section 2: Completed by subject individual / 9 Name of subject individual (Last/First/Middle) / 10 Date of birth
Month: day: year: / 11 Sex
Male/Female / 12 Social Security Number (or INS #)
13 Maiden name, other name(s) used / 14 Driver’s License or ID Card
Number:State:
15 Street address
Street
CityStateZip / 17 Home/Message Phone / 18 Height / 19 Race or ethnicity
(optional)
20 Have you lived outside Oregon during the past 3 years?
If “Yes,” list out-of-state residences during past 3 years. / Yes
No
16 Mailing address (if different than street address)
CityStateZip / CityState/Country / From (Month/Yr) / Until (Month/Yr)
Use additional / paper if necessary.
21 List all arrests and charges that did not result in a conviction, regardless of how long ago.
Date
Estimate if not known / Charge or arrest / Location (City, State)
1
2
3
4
5
6
7
8 /
Use additional paper if necessary.
22 Name of qualified entity / 23 Name of subject individual / 24 Social Security Number
Section 2 (continued): Completed by subject individual / 25 List all convictions, regardless of how long ago(include military convictions).
Date of conviction
Estimate if not known / Crime (include felonies, misdemeanors, probation violations and failures to appear.) / Location (City, State)
1
2
3
4
5 / Use additional paper if necessary.
26 If you have any convictions (Box 25) or arrest history (Box 21), you must explain the circumstances and what you have done to change your life since this history (see Instructions).
Use additional paper if necessary.
27 Probation Officer name (if applicable) / 28 County, State / 29 Phone Number
I understand that a criminal and background history check will be completed on me and the information may be shared with the person listed in Box 1. I certify this information is correct and complete. I understand including my social security number is voluntary. I understand if I provide false or incomplete information, I may be
denied the position. I understand the check may be repeated
as long as I hold this position. I have read and understand
the instructions for completing this form.
Section 3:Completed by AD/CP
/32 I certify that I have reviewed this form and it appears to be complete. Identification/information should be confirmed with photo ID when possible or required.
/Photo ID checked
Photo ID not available /33 Name of person checking ID
34 Preliminary reviewCheck each box that applies
No potentially disqualifying history disclosed
Permanent crime disclosed10 yr crime5 yr crimeProbationary status allowedProbationary status not allowed
Preliminary fitness determination completedNo preliminary FD / 35 AD/CP signature / AD
CP
36 Date signed
37
DHS
USEONLY
/Automatic approval (No FP required)Disposition unknown (AD must investigate)
Potentially disqualified (AD must make FD)5 yr10 yrPermanentFalse
/Reviewer/date
Other:
FP Results on fileAwaiting FBI resultsSee attached letter
Fingerprints requiredResidencyMulti-State HxSelf-DisclosedOther
/REMIT
Criminal Records Unit (CRU) /
Criminal History Request
/CONFIDENTIALINFORMATION
DHS Criminal History RequestInstructions for Subject Individual
Read all instructions before completing form
“Subject individual” is the person whose history is being checked. The Subject Individual must complete boxes 9-31. The “Authorized Designee” (AD) or “Contact Person” (CP) is a person who helps with the check and who has received training from DHS.
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 have an INS number, write your INS number in box 12.
Disclose all history. You must accurately and completely disclose all history requested. This includes all felonies, misdemeanors, probation violations and failures to appear. If you fail to list any part of your history you may be denied. 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. Be certain to include the date (approximate, if necessary) and location (city and state) of each arrest and conviction.
If you have history that you believe is “expunged” or removed from your record, or a crime for which you have been pardoned but you do not have documentation that it was removed, you should list it. A crime is not removed from your record until you complete the formal process to have it removed.
Arrests. In most cases, arrests alone will not result in denial. If, however, you falsify or provide incomplete information, you may be denied.
Federal crimes. List all arrests and crimes. In boxes 21 and 25, if the FBI was involved or if you know that it was a federal crime, you must so indicate.
Violations. Minor traffic violations, such as parking tickets, speeding, failing to stop at a stop sign or red light, are not required to be listed.
If you have any criminal history, you should provide the following information in Box 26. If your history is “potentially disqualifying,” you may be automatically denied if you do not answer these questions in Box 26.
Tell us what happened when you were arrested and/or convicted.
What did you have to do because of the arrest or conviction? Serve probation? Pay restitution?
List any treatment, counseling program, alcohol or drug rehabilitation, education, and training.
List employment demonstrating responsible behavior.
How is your criminal history relevant to your job or position?
How has your life changed since the criminal history?
Why do you believe you are no longer a risk to vulnerable people?
Explain why you believe past bad behavior is not likely to recur.
Attach documentation to support information provided. / DHS Criminal Records Unit
PO Box 14870
Salem, Oregon 97309-5066
Toll-free: (888) 272-5545
OUTCOME / Denial. You may be denied if you were convicted of a crime, you falsify or fail to disclose requested information, or you are a registered sex offender. You may be denied if you have a probation violation, outstanding warrant, deferred sentence or unresolved arrest. You may be denied if you are on probation. If you are “denied” you may not hold the position/job and must be terminated immediately.
Failure to cooperate. If you do not cooperate with this process, your application may be closed without a fitness determination and you will not have a right to appeal the decision.
Additional Information and InstructionsAuthority. The Department of Human Services (DHS) is authorized by state law to complete criminal and other background checks on people who work, volunteer or live with people who are vulnerable to abuse or mistreatment. Vulnerable people include children, senior citizens and persons with physical disabilities, developmental disabilities or mental illness. A check may be required even if the Subject Individual does not have direct contact with vulnerable people.
Results. Results from this request are returned to the Authorized Designee listed in box 1. If the Qualified Entity has a Contact Person, but no authorized designee, DHS will complete the fitness determination without returning LEDS information to the contact person.
Sources checked. In doing this check, DHS may use information from the Driver and Motor Vehicle Division; Department of Corrections; Oregon State Police; Federal Bureau of Investigation; and local, state, and federal courts. DHS may use information from other criminal justice, corrections, law enforcement agencies, and other state and local government agencies. Fingerprints may be requested by the DHS Criminal Records Unit (CRU). In some cases, we may check current and previous employers.
Challenging state information. The Subject Individual may look at the criminal history information (LEDS record) provided by the Oregon State Police. If the subject individual wants to obtain a copy of the record, or challenge information in the record, the subject individual must contact the Oregon State Police, (503) 378-3070, extension 330.
Challenging FBI information. The subject individual may challenge the accuracy and completeness of information in the FBI record if he or she believes it is incorrect. To obtain a copy or challenge the FBI record, the subject individual must contact the Federal Bureau of Investigation for information, (304)6253878.
Civil rights. Subject individuals may have rights under TitleVII of the Civil Rights Act of 1964. Discrimination by an employer on the basis of arrests alone may violate federal law. Individuals wishing to obtain information regarding civil rights should contact the Oregon Bureau of Labor and Industries, (503)731-4075, or the U.S. Equal Employment Opportunity Commission (EEOC), (800) 669-4000.
Rechecks. This background check process may be repeated by the qualified entity at any time while the subject individual works, resides, or otherwise continues in this position. It is recommended that the qualified entity request the subject individual notify the qualified entity if they are arrested or convicted for any misdemeanor or felony after completing this form.
Questions? Call (888) 272-5545 (toll-free) or (503) 378-5470
When faxing form to DHS CRU
use the following numbers:
(503) 378-2588(SPD)
(503) 378-2589(Child Welfare)
(503) 378-4480(MH or DD)
(503) 378-6314(all others)
Attach additional pages as necessary. / Codes for Qualified Entity (Box 2)
A&DAlcohol and drug
ALFAssisted living facility
CWChild welfare
DDDevelopmental disabilities
DHSDepartment of Human Services / FHFoster home
RCFResidential care facility
RCHResidential care home
RTFResidential training facility
RTHResidential treatment home
If you need this form in large print or in a different format,
call the Criminal Records Unit toll-free: (888) 272-5545
1
Page /Read all instructions before completing form
/ DHS 0301 (9/14/04)