Fillable Background Check Checklist (Oregon)

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Background Check Checklist (Oregon)

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Page 1 of 2 ORCHARDS Checklist (revised 7/22/2020)
Background Check Checklist:
Information You Will Need to Submit a
Background Check into ORCHARDS
With ORCHARDS, the Background Check Unit
is no longer using the background check
request form (MSC301) or its various versions. This system is meant to work paperlessly. However, you can
use this checklist to gather information you will need about a subject individual (SI) when submitting a new
background check request into ORCHARDS. See page 2 for more information on Dropdowns mentioned in the
list below.
Subject individual (SI) Information Required Fields Marked with Asterisk (*)
□
Social Security # (Note This is voluntary. The SI must approve):
□
*Complete Name:
□
*Date of birth (mm/dd/yyyy):
□
*Residential address:
□
Mailing address (if different):
□
*Prior names and aliases:
□
*Gender: □Male □Female □Unknown/Not Specified □Other □Both
□
*Phone: *Type of Phone (home, mobile, etc.):
□
2
nd
Phone: Type Phone:
□
*Email:
□
Residential History outside OR, past five years (SI will also disclose this):
Pre-Employment Information Required Fields Marked with Asterisk (*)
□
*Provider (Already listed or from dropdown):
□
*Request type (From dropdown):
□
*Position Category (Already listed or from dropdown):
□
*Position (From dropdown):
□
*Position Description (include worksite location; you can also upload on Verify Identity page):
□
*Employee Type (from dropdown):
□
Position Requires Direct Contact with: □Adults □Children □Confidential Information
□Finances/Financial Records □Information Technology Systems □Secure Facilities □Seniors
□
Position Requires: □Driving
Applicant: Verify Identity Required Fields Marked with Asterisk (*)
□
*Document (from dropdown):
□
*Issuing State/Authority:
□
*Document Number:
□
*Expiration Date:
□
Identity Document to upload (can be .doc, .pdf, .jpg, etc.).
Page 2 of 2 ORCHARDS Checklist (revised 7/22/2020)
DROPDOWN DETAILS
Provider dropdown: If you are associated
with more than one qualified entity (QE), or
your QE is split into different CMS
requirements, you will see a dropdown.
Choose the correct QE where the SI will be
working.
Request Type: Request types (formerly
called app types) are specific to each QE
and will determine other fields on this page.
Choose the correct request type for your SI.
Position Category: If this is not already
listed, you will need to choose the correct
CMS category from the following:
• Executive, Administrative, Managerial
• Professional/Licensed Health Care
• Technical, Unlicensed Health Care
(including AFH paid and HCWs)
• Laboratory and Radiology Services
• Food and Dietary Services
• Housekeeping and Engineer Services
• Any other direct access employee
Position: All position titles are now in a
dropdown list. If you do not see the SI’s
position, you may have chosen the incorrect
Request Type or Position Category. If you
still cannot find the Position Title, please
choose “other,” include the position and full
description in the Position Description box,
and send an email to
bcu.info@dhsoha.state.or.us with your
agency, request type, and needed position.
Employee Type: Depending on the request
type you have chosen you will see one or
more of the following. Choose one:
• Employee
• Contractor
• Employment Agency
• Volunteer/Student
• Not Providing Care
• Licensee
• Owner
• Household Member
[Identity] Document: You can confirm an
SI’s identity with a government-issued
photo identification. The following are
listed in ORCHARDS:
• Oregon State Issued Driver’s License
• Oregon State Issues Identification
Card
• Non Oregon State Issued Driver’s
License
• Non Oregon State Issued
Identification Card
• United States Armed Forces ID
• Passport
• Visa
• High School/College ID
• Other Government-Issued Photo ID
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Completed 30 April 2021

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