Within the State of Hawaii, individuals who wish to work in positions requiring direct contact with clients served by the Department of Human Services, particularly within the Med-QUEST Division, may find themselves navigating the nuances of the DHS 1200 form. This form is an integral part of the process for those seeking exemptions from the customary criminal history record and background check standards mandated for such roles. It serves as a request for exemption, marking a critical step for prospective direct service providers who may have past criminal convictions or confirmations of abuse yet believe these should not bar them from serving in these capacities. The form meticulously outlines the necessary information and rationale required to consider an exemption, including detailed accounts of the applicant's intended service role, reasoning for exemption eligibility, and any relevant mitigating factors or rehabilitation efforts post-conviction or abuse confirmation. Additionally, it requests a list of references to substantiate the applicant's claim for reconsideration, alongside an open section for any further comments the applicant wishes to add regarding their request. This comprehensive approach allows for a nuanced review of each individual's case, aiming to balance the safety and integrity of client services with opportunities for redemption and rehabilitation for those with past offenses.
| Question | Answer |
|---|---|
| Form Name | Form Dhs 1200 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | arkansas dhs forms online dhs 1200, how to fill dhs form, dhs 1200, dhs 1200 form |
State of Hawaii |
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DEPARTMENT OF HUMAN SERVICES |
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REQUEST FOR EXEMPTION
(from Criminal History Record and Background Check Standards)
Section I: Individual Seeking Exemption
Print Name:
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Last |
First |
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M.I. |
Signature |
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Social Security No.: |
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Birth Date: |
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Home Address:
Mailing Address:
Home Telephone: |
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Business Telephone: |
Section II: Reasons for Exemption
COMPLETE ALL OF THE FOLLOWING ITEMS. Use additional sheets of paper if necessary.
1.Identify the agency and/or client that you will serve as a direct service provider (or serve in direct contact):
2.Describe the type of service you would be providing for the agency and/or client:
3.Why do you believe an exemption should be given for your criminal conviction or confirmation of abuse? Explain:
4.Concerning your criminal conviction or confirmation of abuse, were there things about the commission of the crime or abuse that would demonstrate that it is unlikely to occur again? Explain:
DHS 1200 (REV. 10/15)
5.List all significant activities/dates since your criminal conviction or confirmation of abuse, such as employment, participation in therapy or education:
6.References. List your references below and provide telephone numbers where they may be contacted. In providing this information, you are consenting to the Department of Human Services or their designee, contacting these individuals for reference verification purposes. Written statements of support may also be submitted:
7. Other comments you may wish to make regarding your exemption request:
8.SEND COMPLETED REQUEST FOR EXEMPTION FORM TO:
Fieldprint, Inc.
12000 Commerce Parkway Suite 100
Mount Laurel, NJ 08054
DHS 1200 (REV. 10/15)