Are you an Oregon resident who needs to identify a child care provider? If so, then the Oregon Department of Human Services (DHS) has just the form for you! The DHS Child Care Provider Form allows parents and guardians in Oregon to find information about certified childcare providers in their area. This blog post will provide detailed instructions on how to submit the form correctly and answer any frequently asked questions that may arise. Keep reading to learn more about the important role this form plays in providing quality care for your child.
| Question | Answer |
|---|---|
| Form Name | Oregon Dhs Child Care Provider Form |
| Form Length | 16 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 4 min |
| Other names | child care provider listing form, dhs in oregon daycare reimbursent form for foster care, oregon dhs listing form, oregon dhs provider |
Child Care Provider Listing
Form Instructions
Parent: Please immediately give this form to your child care provider to complete.
Provider: For help completing this form contact your local Child Care Resource and Referral
(CCR&R) office. To find an office near you call: CCR&R Centralized Coordination at
Licensing and
»If you are currently licensed with the Office of Child Care (OCC), go to page 4 for instructions.
»If you are not licensed with OCC and:
•You are not related to all children in care.
O You are likely providing
•You are a grandparent,
O You are likely providing
Are you required to be licensed with the Office of Child Care?
Child care providers are legally required to be licensed with OCC unless they are exempt from licensing
How to determine your license or
Please select all the statements below that apply to you.
If you provide care in a home, you are exempt from licensing if:
You are providing care in the home of the child but do not live with the child.
All the children you care for, not including your own children, are from the same family. You are caring for three or fewer children, not including your own children, at any one time. You are related to the children in care by blood, marriage or adoption.
If you provide care in a facility, you are exempt from licensing if:
You do not care for children more than 70 days in a year.
A school district, political subdivision of the state or a governmental agency operates the program. You are operating a
If you meet one of the above exemptions, OCC may not require licensing of your home or facility. To see if you need to be licensed, call OCC at
ODHS uses this information to help determine if you need to be licensed with OCC. This is an informational tool only.
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Instructions for
Training
If OCC does not require you to have a license and you are not related to all children in care, you will need to complete the following before submitting a completed Child Care Provider Listing Form:
•Introduction to Child Care Health & Safety training (take online)
O Online training:
•Recognizing and Reporting Child Abuse and Neglect training
O
O Online training:
•Infant/Toddler CPR/First Aid training
For training locations, contact your local CCR&R at
Attach a copy of your “Infant/Toddler CPR/First Aid Card” to this form if you took this training from another agency besides the local CCR&R.
Note: The director and staff members who work with children in care and volunteers who may have unsupervised access to children are also required to take the above trainings.
Water testing requirements
Please note: Lead testing is not needed if you provide care in the child’s home and you live somewhere else.
OCC can reimburse you for the cost of lead testing. For a reimbursement form and information on how to test your water, visit
For information on preventing exposure to lead, contact OCC at
After completing the above trainings and water testing:
•Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
•Mail the form within 30 days from the date issued in the “ODHS branch use only” section. Mail to the Direct Pay Unit (DPU) at P.O. Box 14850, Salem, OR
•Contact DPU for questions at:
•OCC must conduct a home/facility visit before approving you as a child care provider. This also includes care provided in the child’s home. After ODHS reviews your provider listing form and verifies you have completed trainings, an OCC staff person will contact you to schedule a visit where child care will be provided. The OCC staff person will check to make sure the home/facility meets all
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health and safety requirements as required by OCC and ODHS. The staff person can talk with you about concerns or questions you have and share resources or training material.
OBefore this visit, you may review the OCC’s Health and Safety Checklist. Find the checklist at
Please also see section “Additional information for both relative and
Instructions for
Note: A relative is a grandparent,
Training
If you are not required to be licensed with OCC and you are related to the child or children in care, you will need to complete the following before submitting a completed Child Care Provider Listing Form:
•Introduction to Child Care Health & Safety training (take online)
For more information, go to
After completing the above training:
•Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
•Mail the form within 30 days from the date issued in the “ODHS branch use only” section. Mail to the Direct Pay Unit at P.O. Box 14850, Salem, OR
•Contact DPU for questions at
Additional information for both relative and
Background checks
ODHS conducts FBI fingerprint background checks for
•DPU will submit the completed listing form to the Background Check Unit (BCU) to conduct the background checks. You will receive a letter stating who needs to submit fingerprints. Please read this letter carefully; it will have specific instructions on how to get the required fingerprints.
O Criminal and child protective service records checks are required for the provider, any member of the household who is age 16 or older, and any visitors to the home who may have unsupervised access to a child in care. A visitor is someone who may spend time at the provider’s home during the time child care is provided but does not live in the home. This is likely when the provider needs to visit another area of the home (bathroom, bedrooms, kitchen), leaving the visitor an opportunity for unsupervised access to children.
O In facilities exempt from licensing, the site director and everyone who works in the facility who will have access to the children in care need criminal and child protective service records checks. This includes employees, substitute caregivers, staff and volunteers who may have an opportunity for unsupervised access to children.
Persons who have lived in the state for less than five years will require additional child welfare, sex offender and criminal interstate checks.
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Instructions for
family, certified family, certified center)
Licensed providers with OCC are required to:
•Meet ODHS provider requirements and health and safety standards.
•Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
•Mail the form within 30 days from the date issued in the “ODHS branch use only” section. Mail to the Direct Pay Unit at P.O. Box 14850, Salem, OR
A Child Care Provider Listing Form is required for each site where care is provided. ODHS will
need to list and approve each site to receive subsidy child care payments.
Contact DPU for questions at
Important information for all child care providers
Notice
The Oregon Department of Human Services (ODHS) helps pay child care costs for families receiving child care assistance. The family may have to pay for some of the care, including the first month of service, if ODHS does not approve their provider’s listing before their child starts care.
ODHS helps pay child care costs for families receiving assistance.
Providers are required to meet all ODHS standards and provider requirements to be eligible for payment from ODHS. For full standards and requirements, see the ODHS Child Care Provider Guide (DHS 7492) or visit
•This is not a billing form. You will receive a billing form in the mail if ODHS approves you to receive payment as a child care provider and the parent is eligible for child care assistance.
•The family may also be responsible to pay for some of the care, including the first month of care.
•If there is more than one provider for a child, each provider will receive a percentage of the hours for each month.
•For more information regarding child care, go to the ODHS child care information website:
•By supplying your email address in #3 of the listing form, ODHS will email you important information on the child care program.[LJ2][SE3]
Important contacts
•Direct Pay Unit (DPU): P.O. Box 14850, Salem, OR
•Child Care Resource and Referral Centralized Coordination:
•211info: Dial 211 or text the keyword “children” to 898211 or email children@211.org
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•SEIU — Union for
•AFSCME — Union for OCC licensed providers:
Reporting changes
All child care providers are required to report the following changes to DPU within five days by calling 1-
•Any new arrests, indictments, convictions or involvement with Child Protective Services (Child Welfare) or any other agencies providing child or adult protective services by any of the following:
O You
O Any person living with you age 16 and older O Visitors
O Each person supervising a child in the provider’s absence
O The site director of an exempt child care facility and anyone who works in the facility who has access to the children in care, including employees, substitute caregivers, staff and volunteers and
O Any other person required to be on the listing form.
•Any change to the provider’s name, phone number or address including any location where care is provided
•Any new person (age 16 and older) in the home or facility, including visitors to the home or facility during the hours care is provided who may have unsupervised access to the children in care
•If I am now licensed with OCC or have changed my license type with OCC
•If I am no longer licensed with OCC
•If I no longer meet ODHS provider requirements including health and safety requirements
•If I am now a home care worker for any ODHS Aging and People with Disabilities programs or personal support worker through any Intellectual and Developmental Disability (IDD) or Oregon Health Authority (OHA) Behavioral Health Services program
•If I am a home care worker or personal support worker, I will notify DPU if any changes occur with the type of care I provide or if clients have been added to my care
Failure to report changes may result in a fail status or suspension as a child care provider and you will not be able to receive child care payments.
Frequently asked questions and full standards and requirements
See the ODHS Child Care Provider Guide (DHS 7492) or visit:
Where to submit the completed form
By mail: Direct Pay Unit, P.O. Box 14850, Salem, OR
By fax:
By email: DPU.childcarebilling@dhsoha.state.or.us (PDF only)
Questions? Call
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Child Care Provider Listing Form
All child care providers are required to complete this form.
ODHS branch use only
Case name:
Case number:
Program:
Branch:
Billing form:
CCB
JCCB
Date issued:
Date care began:
Will this be the primary provider?
Yes No
Percent of care for this provider:
1st month: |
2nd month: |
If ERDC, copay month:
Copay amounts: |
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1st month: |
2nd month: |
Replaces another provider?
Yes No
If yes, ended care with this provider:
Date care ended (mm/dd/yy):
DPU |
DPU worker:
Provider number:
Notes:
Child care provider section — use blue or black ink
1. Name as it appears on IRS records:
2. SSN or IRS number:
3. Email:
4. |
Name to be printed on the check: |
5. |
Address where you provide child care*: |
City: |
State: |
ZIP: |
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6. |
Phone number: |
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7. |
Address where you live: |
City: |
State: |
ZIP: |
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8. |
What language do you prefer? |
9. |
Mailing address (if different): |
City: |
State: |
ZIP: |
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*Note: If you provide child care at more than one address, attach a separate sheet of paper with the additional addresses.
10. |
Check this box if you are currently licensed with the Office of Child Care (OCC). |
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Write your OCC license number here: _______________________________ |
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11. |
Check this box if you are a child care facility that is exempt from licensing with OCC. |
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12.Were you ever a child care provider in another state? If yes, list the city and state:
________________________________________________________________
13.Ethnicity: Racial heritage:
Hispanic/Latino |
Not Hispanic/Latino |
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Asian |
White |
Black or African American |
American Indian/Alaska Native |
Native Hawaiian/Pacific Islander |
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You can choose not to give the above ethnicity and racial heritage information. Your provider status will not be affected.
14. Is the home where care is being provided foster care certified? (This applies if you provide care in
your own home.) |
Yes |
No |
If yes, attach a letter from the ODHS foster care certifier approving you to do child care in that home or your listing will be failed.
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15. Do you provide (or will you provide) child care in the home where the child lives?
Yes
No
16. a) Are you working or approved to be a homecare worker (HCW) through any Aging and People with
Disabilities (APD) programs? |
Yes |
No |
b) If yes, write your provider number here even if you do not currently have clients: _____________
c) Are you currently providing service for client(s) in APD programs?
Yes
No
d) Are you working or approved to be a personal support worker (PSW) through any ODHS
Intellectual and Development Disability (I/DD)? |
Yes |
No |
e) If yes, write your provider number here even if you do not currently have clients: _____________
f) Are you currently providing service for client(s) in I/DD programs?
Yes
No
If you are a homecare or personal support worker and you are currently servicing clients, please attach a separate paper with your work schedules (days/times) for each type of care you provide (or will provide), as well as the child care schedule. The listing form is incomplete and will be returned if schedules are not attached. Additional information may be requested to determine child care provider eligibility.
Notify DPU if changes occur with the type of care you provide or if you have added clients to your care.
17.List the children of the ODHS families who will be in your care. (Attach a separate paper if necessary.)
Child’s name (first and last)
Birth date
Check the correct box if you are a relative* of the child in care:
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Grandparent |
Great grandparent |
Sibling |
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Aunt or uncle (do not include great) |
Not related |
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Grandparent |
Great grandparent |
Sibling |
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Aunt or uncle (do not include great) |
Not related |
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Grandparent |
Great grandparent |
Sibling |
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Aunt or uncle (do not include great) |
Not related |
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*Relationships must be by blood, adoption or marriage. This includes biological relatives. Relationships by marriage continue even if a spouse dies.
Please answer the following questions:
18.I am the parent, stepparent or legal guardian of the child in care.
19.I am on the same Temporary Assistance to Needy Families (TANF) case or Employment Related Day Care (ERDC) case as the child.
20.I am a sibling and live in the same household of the child who will be in care.
21.I hold a medical marijuana card or distribute, grow or use marijuana (including medical marijuana) or any controlled substance (except lawfully prescribed and
Yes
Yes
Yes
Yes
No No
No No
If you answered “Yes” to any of the above questions, you are not eligible to be listed as an ODHS child care provider. Do not proceed.
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22. Basic provider requirements
All child care providers, including those licensed with OCC, are required to answer this section.
Do you meet the
requirements?
A. If required by law, I will be licensed with the Office of Child Care (OCC). |
Yes |
No |
See the page 1 of instructions section for more information. |
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B. I am age 18 years of age or older and I understand that I am legally responsible |
Yes |
No |
for the accuracy of this form and to repay any payment made in error. |
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C. I am the actual person or facility providing care for the children. |
Yes |
No |
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D. I am competent and have sound judgement and |
Yes |
No |
with children. |
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E. I am mentally, physically and emotionally capable of performing duties related to |
Yes |
No |
child care. |
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F. I will keep billing records and daily attendance records that show the |
Yes |
No |
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G. If requested, I will allow ODHS to review billing records and attendance records. |
Yes |
No |
I understand that I will incur an overpayment when attendance records are not |
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submitted for verification. |
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H. I will treat ODHS families the same as other families receiving care |
Yes |
No |
including charging ODHS families the same rate (or less) than I normally |
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charge |
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I. I agree to have or develop a policy for removal and suspension of a child from the |
Yes |
No |
child care setting and communicate this policy to parents/caregivers. |
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J. I agree to complete the ODHS Child Care Orientation class within 90 days of |
Yes |
No |
being approved with ODHS if I am not required to be licensed with OCC, am a |
N/A |
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new provider or am relisting after a break of one year or more. |
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K. I will allow ODHS to inspect or visit the site of care during the hours child care |
Yes |
No |
is provided. |
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L. I will provide proof that I meet the ODHS requirements when requested. |
Yes |
No |
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If you answered “No” to any of the above questions, you are not eligible to be listed as an ODHS child care provider. Do not proceed.
23. Home/facility requirements
All child care providers, including those licensed with OCC, are required to answer this section.
If OCC does not require you to be licensed (exempt from licensing), there may be help in meeting the following requirements. Please contact DPU for more information. You may print a safety and quality reimbursement form at: http://triwou.org/projects/ccccrr/professionals.
Does your
home/facility meet the requirements?
A.Does each floor used by children have two usable outdoor exits? (This can include a sliding door or window that can be used to evacuate children.)
1.If there is a second floor used for child care, I have or will have a written plan for evacuating children.
Yes
Yes N/A
No
No
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23. Home/facility requirements, continued
Does your home/facility meet the requirements?
B. Does the home/facility have safe water for drinking or preparing food? |
Yes |
No |
1. If you are a |
Yes |
No |
you attached the lead test results to this form? See the information page 2 for |
N/A |
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more information. |
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C. Does the home/facility have a working smoke detector on each floor and in each |
Yes |
No |
area where children nap? |
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D. Will you ensure that the building, grounds, toys, equipment and furniture are |
Yes |
No |
clean, sanitary and |
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E. Does the home/facility have a working telephone? (You must note phone number |
Yes |
No |
in question 6.) |
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F. Are there barriers to protect children from fireplaces, space heaters, electric |
Yes |
No |
outlets, wood stoves, stairways, pools, ponds and other hazards. All gates and |
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enclosures must not pose a risk or hazard to any child in care. |
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G. Will you ensure that items dangerous to children are kept in a secure place out of |
Yes |
No |
a child’s reach? These items include firearms, ammunition, alcohol, inhalants, |
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tobacco and |
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and toxic materials. |
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If you answered “No” to any of the above questions, you are not eligible to be listed as an ODHS child care provider. Do not proceed.
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24. Promoting safety |
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Do you meet the |
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All child care providers, including those licensed with OCC, are |
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requirements? |
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required to answer this section. |
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A. I will make sure that no one smokes or carries any lighted smoking instrument, |
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Yes |
No |
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including |
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•In the home or facility or within 10 feet of any entrance, exit, window that opens, or any ventilation intake that serves an enclosed area, during child care operational hours or anytime child care children are present and
•In motor vehicles when child care children are passengers.
B. I will make sure that no one uses smokeless tobacco: |
Yes |
No |
• In the home or facility during child care operational hours or anytime child care |
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children are present and |
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• In motor vehicles when child care children are passengers. |
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C. I will make sure that no one will be under the influence of alcohol, controlled |
Yes |
No |
substances (except legally prescribed and |
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marijuana (including medical marijuana) on the premises during child care |
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operational hours or anytime child care children are present. |
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24. Promoting safety, continued
Do you meet the requirements?
D. I will make sure that no one consumes alcohol or uses controlled |
Yes |
No |
substances (except legally prescribed and |
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marijuana (including medical marijuana) in motor vehicles while child care |
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children are passengers. |
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E. I will make sure that the following are not on the premises during child care |
Yes |
No |
operational hours or anytime child care children are present: controlled substances |
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(except lawfully prescribed and |
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(including medical marijuana, marijuana edibles and other products containing |
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marijuana), marijuana plants, derivatives and associated paraphernalia. |
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F. I will make sure that child care is not conducted in a halfway house, hotel, motel, |
Yes |
No |
shelter or other temporary housing such as a tent, trailer or motor home. Licensed |
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(registered or certified) care approved in a hotel, motel or shelter is allowed. |
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G. I will make sure that child care is not conducted in a structure that is designed to |
Yes |
No |
be transportable and not attached to the ground, to another structure or to any |
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utilities on the same premises. |
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H. I agree to supervise children in care at all times. |
Yes |
No |
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I. I will make sure that child care providers and any person supervising, transporting, |
Yes |
No |
preparing meals or otherwise working in the proximity of child care children and |
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those completing daily attendance and billing records are not under the influence. |
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J. I agree to prevent people who behave in a manner that may harm children from |
Yes |
No |
having access to children in care. This includes anyone under the influence. |
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K. I agree to report suspected child abuse of any child in care to an ODHS Child |
Yes |
No |
Protective Services (CPS) Office (Child Welfare) or a law enforcement agency. |
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L. I agree to review the immunization schedule with parents and keep immunization |
Yes |
No |
records |
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M. I will take steps to prevent the spread of infectious diseases. |
Yes |
No |
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N. I will allow custodial parents to have immediate access at all times to their children |
Yes |
No |
in care. |
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O. I will comply with state and federal laws related to child safety systems and |
Yes |
No |
seat belts in vehicles, bicycle safety and crib standards under 16 CFR 1219 |
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and 1220. |
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P. I will place infants on their backs to sleep, as recommended by the American |
Yes |
No |
Academy of Pediatrics, if I provide child care to infants. |
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If you answered “No” to any of the above questions, you are not eligible to be listed as an ODHS child care provider. Do not proceed.
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25.
Complete only if you are not licensed as a provider with OCC. Go to section 26 if you are licensed with OCC.
Do you meet the
requirements?
Child care providers not licensed with OCC
Note: The director, staff members and volunteers who work with the children in care are also required to take these trainings.
A.I have completed the Introduction to Child Care Health and Safety (ICCHS) online training.
Enter the date you completed this training: ______________
If you marked “No”, your listing form will not be processed until you complete this training. To take this training, go to
Yes
No
Additional trainings for |
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following two trainings before turning in this listing form. For more information see instruction section |
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page 2. If you are related to all children in care, please skip to section 26. |
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B. I have completed the Recognizing and Reporting Child Abuse and Neglect |
Yes |
No |
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(RRCAN) training. |
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Enter the date you completed this training: ______________ |
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If you marked “No”, your listing form will not be processed until this training is |
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completed. To take this training go to www.oregon.gov/dhs/assistance/CHILD- |
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CARE/Pages/training.aspx. or contact your local Child Care Resource and |
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Referral (CCR&R) agency at |
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C. I have completed the Infant/Toddler CPR/First Aid training. |
Yes |
No |
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Enter the date you completed this training: ______________ |
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If you marked “No,” you must complete this training before the listing |
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form will be processed. Strictly online training is not acceptable. |
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Your listing form will be processed if the CCR&R has given you a CPR/first aid |
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waiver. Write your waiver number here: ______________ |
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This waiver is only for |
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regarding the Infant/Toddler CPR/First Aid class. |
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Attach a copy of your “Infant/Toddler CPR/First Aid Card” to this form if you |
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previously took this training from another agency besides the local CCR&R. |
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You will also need to contact the Oregon Registry Online (ORO) at |
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For assistance, go to www.oregon.gov/dhs/assistance/CHILD- |
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CARE/Pages/training.aspx or contact your local CCR&R at |
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http://triwou.org/projects/fcco/sdamap or call 211. |
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26. Provider agreement
All child care providers, including those licensed with OCC, are required to answer this section.
Do you agree?
See the ODHS Child Care Provider Guide (DHS 7492) for complete information or check our website at https://apps.state.or.us/Forms/Served/de7492.pdf. If you need a guide, contact DPU at
A. I agree to the following: |
Yes |
I will report any of the following changes to DPU within five |
No |
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days by calling |
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DPU.ProviderReporting@dhsoha.state.or.us: |
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Note: Failure to report changes may result in a fail status or suspension as a child care provider and you will not be able to receive child care payments.
•Child care providers are required to report any contact or involvement with Child Protective Services (Child Welfare) or any other agencies providing child or adult protective services, as well as any arrests, indictments or convictions, for the following individuals:
O You (child care provider)
O Any person living with you age 16 andolder
O Eachpersonwhovisitsthehomeoftheproviderduringthehourscareis provided and may have unsupervised access to a child in care
O Each person supervising a child in the provider’s absence
O The site director of an exempt child care facility and anyone who works in the facility who has access to the children in care, including employees, substitute caregivers, staff and volunteers, and
O Any other person required to be on the listing form
•Anychangetotheprovider’sname,phonenumberoraddressincludingany location where care is provided
•Any new person (age 16 and older) in the home or facility, including visitors to the home or facility during the hours care is provided who may have unsupervised access to the children in care
•When a person in the home or facility turns 16 years of age
•If I am now licensed with OCC
•If I no longer meet ODHS provider requirements including health and safety requirements
•IfI am nowahomecareworkerforanyODHSAgingandPeoplewith Disabilities programs or personal support worker through any Intellectual and Developmental Disability (IDD) or Oregon Health Authority (OHA) Behavioral Health Services program
•IfI amahomecareworkerorpersonalsupportworker,anychanges that
occurwiththetypeofcare theprovidergivesorifclientshavebeenadded to the provider's care.
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26. Provider agreement, continued
Do you agree?
B. I agree with the provider requirements listed in this Child Care Provider Listing |
Yes |
Form and in the ODHS Child Care Provider Guide (DHS 7492). Go to |
No |
https://apps.state.or.us/Forms/Served/de7492.pdf to view the guide. |
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C. I understand that making false statements or hiding information may subject me to |
Yes |
state or federal penalties. |
No |
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D. I affirm under penalty of perjury that I have given true and complete information, |
Yes |
and my name and Social Security number or IRS identification number is valid |
No |
and correct. |
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E. I affirm under the penalty of perjury that I have reported criminal history and Child |
Yes |
Protective Services (Child Welfare) information completely, and I will repay all |
No |
payments if I do not disclose this information. |
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F. I understand that my child care provider status with ODHS may be disclosed to |
Yes |
other departments within Oregon state government. |
No |
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G. If I choose to be a member of a child care union, I understand that deductions of |
Yes |
dues may be made from my payments. |
No |
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H. I agree to bill ODHS for child care provided during the ODHS families work hours or |
Yes |
ODHS planned activities. |
No |
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I. I understand I cannot bill ODHS for tuition outside of child care to provide educational |
Yes |
instruction or tutoring for school aged children. |
No |
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Provider or director signature |
Date |
Print name of provider or director
Licensed providers with OCC (registered family, certified family and certified centers) STOP HERE and submit this completed form to DPU for processing. Do not complete section 27.
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27. Background checks
This form will be returned as incomplete if there is any missing information.
Providers who are licensed with OCC do not need to answer this section.
Who must complete and sign this section
•Provider
•All household members (age 16 or older). This includes the parent of the child for whom you are providing care if you live together
Note: If you provide care in the child’s home and you live somewhere else, only you, the provider, must complete and sign this question (section 27).
•Substitute or
•Any visitors who may have unsupervised access to a child in care
Unsupervised access applies to most visitors in the provider’s home during child care hours. A visitor is likely to have an opportunity for unsupervised access to children in care when the provider needs to visit another area of the home (bathroom, kitchen or other areas where children nap).
•Facilities that are exempt from licensing — the facility site director and staff, as well as visitors and volunteers with an opportunity for unsupervised access to children, under regulation ORS 329A.250, are subject to criminal and child protective service records checks.
I understand that:
•Each person must pass a criminal history and abuse history check
•Providers must make sure that everyone required to sign the form provides complete and accurate information
•I and any listed individuals must disclose history of:
O All arrests, charges, adjudications and convictions
O Allegations of abuse or neglect and any involvement with child or adult protective services in any state, territory or country at any time
•I and any listed individual must report any new criminal history or abuse history to DPU within five days (see section 26 for more information)
•I will be in failed status for not meeting eligibility if the listing form does not include a required person, or if anyone on the listing form does not provide complete information regarding criminal history (arrests, charges and/or convictions) and child/adult protective service history. If this occurs, I will not be eligible for payment and may incur an overpayment.
The signatures of the listed individuals and myself authorize the Background Check Unit (BCU), ODHS, the state court system and other agencies to:
•Disclose information and communicate it only to determine and review eligibility as an ODHS provider
•Process these background checks and request and receive any juvenile, police, court or investigation reports needed
(In the event the agency discovers potentially disqualifying abuse, I may receive more information at the address or email I have given.)
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•Release information given in this background check request or position information to any criminal justice agency or investigative body as needed for investigation, outstanding warrants or supervision requirements
•Release and receive any abuse and neglect information, provider enrollment records and any other required information between provider enrollment units of ODHS and Oregon Health Authority (OHA)
•Release and receive any abuse and neglect information, provider certification or licensing records, and any other required information between ODHS and the Office of Child Care.
I understand the background check on myself or any listed individuals may be repeated while I remain an active, failed or suspended provider.
I understand that a
•An Oregon criminal records check
•A
•An Oregon abuse history check
•An abuse history check for all states in which the listed individual lived within the last five years
•Persons who have lived in the state for less than five years, which requires additional child welfare, sex offender and criminal interstate checks
•Court records, juvenile records, police investigations, abuse investigations and other documentation as needed to complete the fitness determination.
Child care provider (or site director for a facility)
This form will be returned as incomplete if there is any missing information.
Providers who are licensed with OCC do not need to answer this section.
Name (last, first, M.I.): |
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Other names used: |
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Birth date: |
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Driver license or ID number/state: |
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Social Security number (if none, write N/A): |
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Have you lived outside Oregon in the last five years? |
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No |
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If yes, list previous state(s) and residence dates: |
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Have you ever had a criminal arrest and/or conviction(s)? |
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Have you ever been involved with Child Protective Services (Child Welfare) or any other |
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If any of the boxes are checked “yes”, attach a separate paper explaining all past and current history. Include each incident, date and location.
Authorizing signature:
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Other household members, employees/volunteers and visitors
Household members (age 16 and older), all other employees/volunteers and visitors are required to answer this section.
Each person required to have a background check will need to answer these questions and sign. If you need more space, attach an additional paper to this form.
Name (last, first, M.I.): |
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Other names used: |
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Birth date: |
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Driver license or ID number/state: |
Sex: |
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Social Security number (if none, write N/A): |
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Male |
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I am a (check one): |
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Have you lived outside Oregon in the last five years? |
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No |
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If yes, list previous state(s) and residence dates: |
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Have you ever had a criminal arrest and/or conviction(s)? |
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Have you ever been involved with Child Protective Services (Child Welfare) or any other |
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agencies providing child or adult protective services at any time? |
Yes |
No |
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If any of the boxes are checked “yes,” attach a separate paper explaining all past and current history. Include each incident, date and location.
Authorizing signature:
Name (last, first, M.I.): |
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Other names used: |
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Birth date: |
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Driver license or ID number/state: |
Sex: |
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I am a (check one): |
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Have you lived outside Oregon in the last five years? |
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No |
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If yes, list previous state(s) and residence dates: |
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Have you ever had a criminal arrest and/or conviction(s)? |
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Have you ever been involved with Child Protective Services (Child Welfare) or any other |
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agencies providing child or adult protective services at any time? |
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No |
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If any of the boxes are checked “yes,” attach a separate paper explaining all past and current history. Include each incident, date and location.
Authorizing signature:
Where to submit the completed form
By mail: Direct Pay Unit, P.O. Box 14850, Salem, OR
By email: dpu.childcarebilling@dhsoha.state.or.us (PDF only)
By fax:
Questions? Call
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