Oregon DHS Background Check Request Form MSC 0301 QED

To submit this form, ensure it is completed accurately and all required additional documents are attached. Submit via email to the agency's designated email address, via fax to the agency's fax number, through the agency's online submission form, or via mail to the agency's physical address as indicated in the form's instructions. Ensure to keep a copy for your records. Follow the agency's guidelines for the specific submission process.

There are no specific important dates for this form in 2024 and 2025. The form should be submitted as needed for background checks.

The purpose of the Oregon DHS Background Check Request Form MSC 0301 QED is to collect information necessary for conducting background checks. This form is used by the Oregon Department of Human Services to ensure individuals in specific positions meet the required standards. Background checks help protect vulnerable populations and ensure the safety and security of facilities.

• 1. QE (agency) name: The name of the qualified entity or agency requesting the background check.
• 2. QED name: The name of the Qualified Entity Designee responsible for completing the form.
• 3. Application type in CRIMS: The type of application to be used in the CRIMS system, determined by the SI's position and whether they are paid or unpaid.
• 4. Start date for position: The start date for the position the Subject Individual is applying for.
• 5. Position title: The specific title of the position the Subject Individual is applying for.
• 6. Description of duties: Specific details of the duties required for the position.
• 7. Position requires direct contact with: Indicates whether the position requires direct contact with adults, children, seniors, confidential information, secure facilities, finances/financial records, or information technology systems.
• 8. Do the duties require driving?: Indicates whether the position requires driving.
• 9. Type(s) of documents checked to verify identity: The documents used to verify the identity of the Subject Individual, such as a driver's license, state ID, social security card, passport, or other documents.
• 10. Worksite location(s)/address(es) for this position: The worksite location(s) or address(es) for the position, including all locations if there are multiple.
• 11. Individual name: The last, first, and middle name of the Subject Individual.
• 12. Social Security number: The Social Security number of the Subject Individual (optional).
• 13. Date of birth: The date of birth of the Subject Individual in mm/dd/yyyy format.
• 14. Email address: The email address of the Subject Individual.
• 15. Gender: The gender of the Subject Individual (female, male, unknown/not specified).
• 16. Driver license or ID: The state and number of the Subject Individual's driver's license or ID.
• 17. Aliases/other names used: Any aliases or other names used by the Subject Individual.
• 18. Residence street address: The residential street address of the Subject Individual.
• 19. City: The city of residence of the Subject Individual.
• 20. State: The state of residence of the Subject Individual.
• 21. ZIP code: The ZIP code of the Subject Individual's residence.
• 22. Mailing address: The mailing address of the Subject Individual (if different from the residential address).
• 23. Home phone: The home phone number of the Subject Individual.
• 24. Mobile phone: The mobile phone number of the Subject Individual.
• 25. Out-of-state residence: Whether the Subject Individual has been outside of Oregon for 60 days or more in the last five years.
• 26. Residence history: Details of each residence outside of Oregon for the last five years, including dates, names used, city, state, and country.
• 27. Criminal history: Whether the Subject Individual has ever been charged, arrested, adjudicated, or convicted of a crime.
• 28. Criminal history details: Details of all charges, arrests, adjudications, or convictions, including dates, charges, outcomes, cities, counties, and states.
• 29. Potentially disqualifying history: Additional information about the details of potentially disqualifying history, training, education, work history, treatment, and circumstances that the BCU should consider.
• 30. Signature and date: The signature and date of the Subject Individual authorizing the background check process and release of information.

Failure to submit this form may result in the inability to process the background check and potentially disqualify the individual from the position.

• Application closure: Your application may be closed if the form is not submitted.
• Position denial: You may be denied the position if the required background check information is not provided.

• 1. Employment: Use this form when applying for a job that requires a background check.
• 2. Contracting: Use this form when being contracted for work that requires a background check.
• 3. Volunteering: Use this form when volunteering for positions that require a background check.
• 4. Internships: Use this form when applying for internships that require a background check.
• 5. Household member checks: Use this form for background checks required for household members in regulated environments.