Forms

Background Check Authorization Form with Instructions (DSHS 09-653)

The Background Check Authorization Form is used to request a background check for an applicant in order to meet varying background check needs for DSHS programs and facilities. It is critical to read the instructions to ensure the form is correctly completed. BCCU rejects approximately 37,000 forms a year due to being incomplete and/or illegible.  The DSHS program that is requiring the background check may have additional instructions that you must follow.  View a SAMPLE Background Check Authorization Form for a visual example of the required fields and correct format.

List of Additional Crimes or Pending Charges (DSHS 09-653D)

Optional form to assist applicants in providing all of their self-disclosure information when they have multiple crimes or charges to disclose for questions 11A or 11B on the Background Check Authorization Form (DSHS 09-653). The List of Additional Crimes or Pending Charges Form MUST be attached to the Background Check Authorization Form.


Applicant Affidavit Form (DSHS 27-109)

The BCCU Applicant Affidavit Form is for the applicant to clarify or provide specific details relating to their criminal history or self-disclosure. The applicant may need to clarify or provide additional details on crimes reported by the following sources:

  • Crimes or Negative Actions reported through a centralized database

  • Self-disclosures made on the Background Check Authorization Form

  • Correct errors on the Background Check Authorization Form

IMPORTANT: The Applicant Affidavit Form is not a substitute for the Background Authorization Form. If you need a background check completed for an employee, please use the Background Check Authorization Form.

Visit our FAQ page to find additional information related to Findings and Court Documents.


Applicant Request for a Copy of Background Check Information Form (DSHS  27-110)

The Applicant Request for a Copy of Background Check Information Form is only to be used by the applicant to request a copy of their background check information OR to request a copy of their Additional Information Needed packet. BCCU will not mail or email results to a facility/entity/program using this form.

IMPORTANT: BCCU cannot discuss results with the applicant over the phone until the applicant has a copy of their background information. Please have background check information readily available when contacting BCCU.


Fingerprint-Based Background Check Notice (DSHS 27-089)

Authorized entities who submit fingerprint-based background checks are required to give the Fingerprint-Based Background Check Notice form to the applicant prior to the applicant being fingerprinted.

The Background Check Requestor will need to follow the instructions below:

  1. Provide the Fingerprint-Based Background Check Notice to each applicant who is required to have a fingerprint-based background check.

  2. Have the background check applicant review and sign the Fingerprint-Based Background Check Notice.

  3. Retain a copy of the signed notice for your records and return the original notification to the background check applicant.

  4. Do not fax or mail the notification to BCCU.


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