Forms

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

The Background Check Authorization Form is completed by the applicant and given to the requesting entity.  Applicants also have the option to complete an online version of the Background Check Authorization form. The requesting entity will submit your background check through the online Background Check System (BCS).  The DSHS program that is requiring the background check may have additional instructions that you must follow. 


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. 

EFFECTIVE 07/01/2018:  Applicants will automatically receive a mailed copy of their background check if records found.

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.


DSHS Background Check System (BCS) Access Request (DSHS 17-253)

Authorized entities who submit background checks to BCCU are required to complete the DSHS Background Check System (BCS) Access Request form to request access for a (new) Primary Account Administrators (PAA).

The PAA requesting access will need to complete the form and have it signed by the BCS user's manager/administrator/supervisor and return to BCCU for approval.


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