Dshs 09 653 Form – Fill Out and Use This PDF

Background Authorization

Read the attached instructions before completing this form.

SECTION 1. ENTITY INFORMATION (COMPLETED BY DSHS STAFF, PROVIDER, APPLICANT, LICENSEE, AND/OR CONTRACTOR)

2.NAME AND SIGNATURE OF PERSON REQUESTING THE BACKGROUND CHECK

PRINTED NAME:

SIGNATURE:

3. A. REQUIRED ONLY FOR ECONOMIC SERVICES ADMINISTRATION:

B. REQUIRED ONLY FOR CHILDREN’S ADMINISTRATION:

C. REQUIRED ONLY FOR ADULT PROTECTIVE SERVICES:

Subject involved in (or related to) APS investigation per RCW 74.34

D. REQUIRED ONLY FOR DSHS STATE EMPLOYMENT:
DSHS POSITION NUMBER	(WRITE NONE IF NONE) DSHS JOB CLASSIFICATION:	PERSONNEL IDENTIFICATION NUMBER:

SECTION 2. THIS SECTION IS FOR APPLICANT INFORMATION ONLY (THE PERSON TO BE CHECKED IS THE APPLICANT)

8A.	SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR LAST	SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR FIRST	SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR MIDDLE
NAME AS IT IS NOW (WRITE NONE IF NONE)		NAME AS IT IS NOW (WRITE NONE IF NONE)	NAME AS IT IS NOW (WRITE NONE IF NONE)
8B.	PRINT YOUR LAST NAME AT BIRTH	PRINT YOUR FIRST NAME AT BIRTH	PRINT YOUR MIDDLE NAME AT BIRTH
	(WRITE NONE IF NONE)	(WRITE NONE IF NONE)	(WRITE NONE IF NONE)

9.PRINT OTHER LAST NAMES YOU HAVE USED AND LAST NAMES YOU HAVE BEEN KNOWN BY (WRITE NONE IF NONE)

10.PRINT YOUR NICKNAMES AND ALL OTHER FIRST NAMES YOU HAVE USED AND HAVE BEEN KNOWN BY (WRITE NONE IF NONE)

16.	How many years have you lived in Washington State without living in another state?			Years /		Months
17.	A. PRINT THE STREET ADDRESS WHERE YOU LIVE NOW	CITY		STATE	ZIP CODE		COUNTY

B.SEE INSTRUCTIONS: PRINT THE STREET ADDRESS WHERE YOU LIVED BEFORE YOUR CURRENT ADDRESS

CITY

STATE

ZIP CODE

COUNTY

C.SEE INSTRUCTIONS: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED

18.I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to work with vulnerable adults, juveniles or children. My signature in box number 19 means:

•I give DSHS permission to check my background with any governmental entity and law enforcement agency.

•If a founded finding is identified, I give DSHS permission to give only my name and that a founded finding was identified to any persons or entities in Section 1.

•I give DSHS permission to give all my other background information to the persons or entities named in Section 1.

•This permission is good for 90 days from the date signed. I can change my mind about this permission in writing at any time.

FOR USE BY CHILDREN’S ADMINISTRATION STAFF ONLY

DSHS 09-653 (REV. 01/2008)

INSTRUCTION SHEET FOR FILLING OUT THE BACKGROUND AUTHORIZATION FORM

Background Authorization Instructions – Page 1 of 2

You MUST fill in ALL boxes on this form as instructed. READ the instructions for each Section and each box.

You MUST put an answer in the box. You can put NO, NOT APPLICABLE (N/A), OR NONE– except BOX number 3 –

DO NOT answer any question by putting UNKNOWN or a QUESTION MARK in the box. If you do, the form will be sent back.

	Print clearly with black ink.		Read each question carefully.
Check with your DSHS program to find out if you must fill in boxes marked ”SEE INSTRUCTIONS”
	(This box allows your program to insert their requirements.)
You MUST put an answer in every box and return this form to:			(This box allows the person, program, or entity to insert the
address or fax number where the form is to be returned.)

Most background authorization forms are sent back to the requester for the following reasons:

•Wrong form.

•Blank boxes.

•Bad handwriting.

•Missing or wrong BCCU account number.

•Person under 18 signs the form without a parent or guardian signature.

•Date signed is older than three (3) months from the date BCCU received the form.

SECTION 1: This section must be completed by the person or entity requesting this background check. An entity may be a facility, business, organization, or agency such as a Nursing Home, a Rehabilitation Center, or a DSHS Office.

If you are applying to be a licensed Adult Family Home, Boarding Home, or Nursing Home, SKIP SECTION 1. GO directly to SECTION 2.

1.A. You MUST put the name of the entity or person asking for the background check. An entity may be a DSHS office. A person may be someone applying for a license or a service provider contract. Ask your DSHS program to tell you what person’s name or the name of the entity that is required for this box.

(This box allows your program to insert requirements.)

B.Ask your DSHS program if you are required to fill in the address of the entity or person asking for the background check. Put N/A in this box if NOT required by your program.

(This box allows your program to insert requirements.)

C.This box is ONLY for Children’s Administration. Children’s Administration: Fill in the name of the facility or foster home.

2.You MUST print and sign your name if you are the person asking for the background check. The person who is being checked signs in box 19.

3.DO NOT WRITE ANYTHING IN THESE BOXES UNLESS you are an employee of Children’s Administration, Economic Services Administration, Adult Protective Services or a DSHS hiring authority.

D.Personnel ID Number is the permanent number assigned to every staff person by the Department of Personnel (DOP).

4.You MUST put your BCCU account number in this box. You can find your BCCU account number at http://www1.dshs.wa.gov/msa/bccu/index.htm. If this form is part of your application for license as an Adult Family Home, Boarding Home or Nursing Home, you DO NOT need to give the BCCU account number. You MUST do the following:

•Adult Family home – Put an A in front of your license number.

•Boarding home– Put a B in front of your license number.

•Nursing home– Put an N in front of your license number.

5.A. You MUST ask your DSHS program if they require you to have an ID number or a name in this box.

Put N/A in this box if NOT required by your program.

(This box allows your program to insert requirements.)

B.DSHS ONLY – Put N/A if you are NOT a DSHS staff person using Web Service for fingerprint background checks. This ID number is for DSHS staff to track background checks. Any program may use this box for their own tracking purposes.

DSHS 09-653 (REV. 01/2008)

Background Authorization Instructions – Page 2 of 2

SECTION 2: You MUST fill out this section if you are the person we are checking. Note: A DSHS employee asking for a background check for an Adult Protective Services (APS) or Child Protective Services (CPS) investigation MUST fill out this section as best he or she can.

6.You MAY put your social security number (SSN) in this box. Your SSN is not required to conduct a background check. (This box allows your program to insert requirements.)

7.You MUST fill in your date of birth.

8A. You MUST put your whole name. If you do not have a name to put in this box, you MUST put NONE.

SEE EXAMPLE BELOW.

EXAMPLE:
PRINT YOUR LAST NAME AS IT IS NOW	PRINT YOUR FIRST NAME AS IT IS NOW	PRINT YOUR MIDDLE NAME AS IT IS NOW
NONE	“PRINCE”	NONE

B.You MUST put your whole birth name. You MUST put SAME if any of your names are the same as the names you put in box 8A.

9.You MUST put last names you have used or have been known by. You MUST put NONE if you have NOT used or been known by any other last names.

10.You MUST put any nicknames you have used. You MUST put NONE if you have NOT used any nicknames.

11.You MUST answer YES or NO. If your answer is YES to A. or B., you MUST fill in your conviction and pending charge information.

12.You MUST answer YES or NO.

13.You MUST answer YES or NO.

14.You MUST answer YES or NO. Put YES if the protection order lasted longer than 30 days and it was for the protection of a vulnerable adult, juvenile or child.

15.You MUST put your driver’s license or state identification number in the box. You MUST put the name of the state in the box. You MUST put NONE if you do not have a driver’s license or state identification number.

16.You MUST put the number of years and months you have lived in Washington State without living in another state or country. If you have moved out of Washington to another state or country, you MUST start counting the years and months from the date you moved back to Washington State. Note: You MUST ask your program if you have to get a fingerprint check.

17.A. You MUST fill in the address where you live now.

B.Your program may require you give your old address. Ask your DSHS program. Put N/A in this box If NOT required by your program.

(This box allows your program to insert requirements.)

C.Ask your program if your telephone number is required. You MUST put NONE if you do not have a telephone number.

(This box allows your program to insert requirements.)

18.You MUST read the statement in this box. Your signature under number 19 means you have read and agree to the statements in number 18. This background authorization form does NOT take the place of a public disclosure request for records about a founded finding. Founded finding means a state agency has taken a legal action against someone after an investigation and notice of a decision about abuse, sexual abuse, neglect, abandonment or exploitation or financial exploitation of a vulnerable adult, juvenile or child.

19.You MUST sign your name here. If you are NOT 18 years old, your parent or guardian MUST sign here.

20.You MUST fill in the date you signed this form.

ATTENTION APPLICANTS:

If you want to know the status of your background check form or need information about the BCCU background check process, contact BCCU at: bccuinquiry@dshs.wa.gov

ATTENTION ENTITIES AND DSHS STAFF: You MUST report errors in your address, telephone number or fax number to BCCU at bccuinquiry@dshs.wa.gov or (360) 902-0299. Put your BCCU account number in your email.

DSHS 09-653 (REV. 01/2008)