Oregon DHS Background Check Request Form MSC 0301 QED
This form is used by the Oregon Department of Human Services to gather information for background checks. It includes instructions for both the Qualified Entity Designee and the Subject Individual. The form must be completed and submitted for a background check to be processed.
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How do I fill this out?
To fill out this form, you will need to gather specific information about the background check process. Make sure to follow the instructions provided carefully. Once completed, submit the form to the appropriate agency for processing.
How to fill out the Oregon DHS Background Check Request Form MSC 0301 QED?
1
Gather required information and documents.
2
Fill out Section 1 with information needed by the QED.
3
Pass pages 2-3 to the Subject Individual to complete Section 2.
4
Ensure all necessary additional pages and documents are attached.
5
Submit the completed form along with all attachments for processing.
Who needs the Oregon DHS Background Check Request Form MSC 0301 QED?
1
Employers who need to conduct background checks on potential employees.
2
Contractors who require background checks for clearance to work on specific projects.
3
Volunteers who need background checks to work with vulnerable populations.
4
Students who require background checks for internships or field placements.
5
Household members of a home where background checks are required for certain regulations.
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What are the instructions for submitting this form?
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.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form in 2024 and 2025. The form should be submitted as needed for background checks.
What is the purpose of this form?
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.
Tell me about this form and its components and fields line-by-line.
- 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.
What happens if I fail to submit this form?
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.
How do I know when to use this form?
- 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.
Frequently Asked Question
How do I fill out the Oregon DHS Background Check Request Form?
Collect all necessary information and documents, complete Sections 1 and 2, and submit the form with additional required documents as specified.
What information do I need to fill out this form?
You will need personal details, position-related information, any aliases used, residence history, and information about any charges, arrests, or convictions.
Can I edit this form online?
Yes, you can edit this form online using PrintFriendly's PDF editor. Upload the form, make necessary changes, and download the edited document.
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Upload the form to PrintFriendly, use the signing tool to add your signature, and save the signed PDF.
Can I share this form with others?
Yes, after editing the form on PrintFriendly, you can share it via email or direct link.
What happens if I provide false information on this form?
Providing false or incomplete information may result in the closure of your application or denial of the position.
Is there a way to save my progress while filling out the form?
Yes, you can save the edited form on PrintFriendly and continue from where you left off at a later time.
Do I need to provide my Social Security number?
Providing your Social Security number is optional, but it may help expedite the background check process.
How long does it take to process a background check?
The processing time can vary, but you will be notified once the background check is completed.
What should I do if I have additional questions about this form?
You should contact the agency where you are applying for further assistance and information.
