Get Request For Staff Exclusion List Check Form

Filling out the Request For Staff Exclusion List Check Form is a crucial step in ensuring the safety of service recipients. This guide will provide you with clear, step-by-step instructions to help you complete the form online effectively.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the Request For Staff Exclusion List Check Form and open it for editing.
2. Enter the applicant's information in Part 1. Provide the last name, first name, date of birth, and social security number. Additionally, indicate the applicant type and provide their address along with the facility or provider name.
3. Designate the state oversight agency by circling the appropriate option: OMH, OPWDD, OCFS, DOH, or OASAS.
4. In Part 2, provide the authorized person's information. Clearly print the name, signature, and email address of the authorized person.
5. Include the facility or provider name and address for the authorized person.
6. Insert the authorized person's phone number and, if applicable, the alien registration number.
7. Review all provided information for accuracy. Ensure that all required fields are completed.
8. Once everything is filled out and reviewed, save your changes. You may download, print, or share the completed form as needed.

Complete the Request For Staff Exclusion List Check Form online today to ensure a safe environment for all service recipients.