Background Check Forms
The most current versions of the DHS background check forms are located here. With the addition of abuse checks to the background check process, the provider versions of the 301 have been updated in order to give information and appropriate notice to the subject individual. 301 forms carrying an effective date of 05/10/2011 (05/11) should be incorporated into your process immediately. Not only do they contain improvements that will aid your work, but the older versions are no longer being accepted.
Related forms will also be revised to incorporate this change. As they are updated, the forms will be labeled with the prefix MSC (previously DHS) to facilitate ease of use by both DHS and the Oregon Health Authority.
If you eSubscribe to updates on our site, you will be notified when the forms are in place. Otherwise, please refer to this forms page periodically.
| Form Number |
Form Name
|
Revision date |
| MSC 0298 |
Authorized Designee/Contact Person Application (Contact BCU's training coordinator for the training packet): (PDF) (Word) |
06/30/2011 |
| MSC 0299 |
NEW Hearing Request: English: (PDF) (Word) |
09/07/2011 |
DHS 0299
Spanish |
Hearing Request: En Español (Word) |
01/04/2010 |
| DHS 0299HR |
Hearing Request - for Abuse and Criminal Records Checks with Adverse Outcomes (To be used only by DHS or OHA for background checks originating on the 301HR form): (Word) |
10/30/2009 |
| MSC 0300 |
NEW Notice of Final Fitness Determination: English: (PDF) (Word ) |
09/07/2011 |
DHS 0300
Spanish |
Notice of Final Fitness Determination: En Español (Word) |
01/04/2010 |
| MSC 0301AD |
Background Check Request (for use when the final fitness determination will be conducted by an Authorized Designee): (PDF) (Word) |
05/10/2011 |
MSC 0301AD
Spanish |
Background Check Request (for use when the final fitness determination will be conducted by an Authorized Designee): En Español (PDF) (Word) |
05/10/2011 |
| MSC 0301CP |
Background Check Request (for use when the final fitness determination will be conducted by the DHS Background Check Unit): English: (PDF) (Word) |
05/10/2011 |
MSC 0301CP
Spanish |
Background Check Request (for use when the final fitness determination will be conducted by the DHS Background Check Unit): En Español (PDF) (Word) |
05/10/2011 |
MSC 0301AD/
CP Instructions |
Background Check instructions for Authorized Designees/Contact Persons: (PDF) (Word) |
05/10/2011 |
| DHS 0302 |
Notice of Closed Case (for providers when final fitness determination not completed) (PDF) (Word) |
02/19/2010 |
| DHS 0303SA |
Criminal History Check - Supplement for Personnel Services or Staffing Agencies: (PDF) (Word) |
01/04/2010 |
DHS 0309
|
Weighing Test Worksheet for Providers. Optional form to use when conducting a weighing test as part of a preliminary or final fitness determination using OAR 407-007-0200 to 407-007-0370 (Word) (Handwritten version) |
01/10/2011 |
NA
|
CJIS Security Clearance Background Request (for AD/CP certification) (PDF) |
03/2011 |
|
