Background Screening Forms

Every individual submitting to a background screening must be provided with a summary of their Privacy Rights.

Please use the Background Submission Checklist and FBI-DCI Code List to ensure all forms are filled out correctly.

All applicants must submit a Central Registry screening request:

• PDF Central Registry Form
• Fill-able Central Registry Form (Word)

If you are a traditional provider, WDH supervisor or PHN supervisor, please include a Cover Sheet for Authorized Providers:

• PDF Cover Sheet for Authorized Providers
• Fill-able Cover Sheet for Authorized Providers (Word)

If you are an Employer of Record under the Self-Directed Waiver Program, please include a Cover Sheet for Self-Directed Care Providers:

• PDF Cover Sheet for Self-Directed Care Providers
• Fill-able Cover Sheet for Self-Direct Care Providers (Word)