Submit To: Marion County Health Department 3876 Beverly AVE NE, Bldg G Salem, Oregon 97305 FAX: 503-361-2782 ATTN: CII Background Check Coordinator	3. SI Original Start Date:
4. SI Job Title: (Provider, Co-Provider, Resident Manager or Caregiver. May also be family member or tenant living in AFH)
Description of Duties:
5. Contact with: Children	Adults	Seniors	Licensed Provider Name: (Print)
6. Do the duties include driving?	Yes	No	Worksite Address:
7. DHS Program Area Child Welfare Volunteer Developmental Disability	Mental Health Senior Branches Senior Facilities Vocational Rehabilitation	Provider Email Address:
FOR ADMINISTRATION USE ONLY Date Received:

Criminal History
Cover Sheet Form

Step 1. Licensed provider or resident manager completes the cover sheet.

Step 2. Applicant completes Subject Individual portion of the DHS 301qed.

Step 3. The provider can mail or deliver the completed background request (DHS 301) with photo ID attached to 3876 Beverly AVE NE, Bldg G, Salem, Oregon 97305. ATTN: Tanya Shackelford

My signature below signifies that I have viewed and verified this applicant’s photo ID and give authorization to the Marion County QED to complete the background check.	Licensed Provider/Resident Manager signature	Date
Please note: Incomplete cover sheets and/or applications will not be accepted and will be returned to the Licensed Provider for completion which will delay the application process.

QED Initials:	Date: