Get HI DHS 1200 2015-2024

Concerning your criminal conviction or confirmation of abuse were there things about the commission of the crime or abuse that would demonstrate that it is unlikely to occur again Explain DHS 1200 Rev. 10/15 5. State of Hawaii DEPARTMENT OF HUMAN SERVICES Med-QUEST Division REQUEST FOR EXEMPTION from Criminal History Record and Background Check Standards Section I Individual Seeking Exemption Print Name Last First M. I. Signature Social Security No* Birth Date Home Address Mailing Address Home Telephone Business Telephone Section II Reasons for Exemption COMPLETE ALL OF THE FOLLOWING ITEMS* Use additional sheets of paper if necessary. 1. Identify the agency and/or client that you will serve as a direct service provider or serve in direct contact 2. Describe the type of service you would be providing for the agency and/or client 3. Why do you believe an exemption should be given for your criminal conviction or confirmation of abuse Explain 4. List all significant activities/dates since your criminal conviction or confirmation of abuse such as employment participation in therapy or education 6. References. List your references below and provide telephone numbers where they may be contacted* In providing this information you are consenting to the Department of Human Services or their designee contacting these individuals for reference verification purposes. Written statements of support may also be submitted 7. Other comments you may wish to make regarding your exemption request 8. SEND COMPLETED REQUEST FOR EXEMPTION FORM TO Fieldprint Inc* 12000 Commerce Parkway Suite 100 Mount Laurel NJ 08054. State of Hawaii DEPARTMENT OF HUMAN SERVICES Med-QUEST Division REQUEST FOR EXEMPTION from Criminal History Record and Background Check Standards Section I Individual Seeking Exemption Print Name Last First M. I. Signature Social Security No* Birth Date Home Address Mailing Address Home Telephone Business Telephone Section II Reasons for Exemption COMPLETE ALL OF THE FOLLOWING ITEMS* Use additional sheets of paper if necessary. I. Signature Social Security No* Birth Date Home Address Mailing Address Home Telephone Business Telephone Section II Reasons for Exemption COMPLETE ALL OF THE FOLLOWING ITEMS* Use additional sheets of paper if necessary. 1. Identify the agency and/or client that you will serve as a direct service provider or serve in direct contact 2. 1. Identify the agency and/or client that you will serve as a direct service provider or serve in direct contact 2. Describe the type of service you would be providing for the agency and/or client 3. Why do you believe an exemption should be given for your criminal conviction or confirmation of abuse Explain 4. List all significant activities/dates since your criminal conviction or confirmation of abuse such as employment participation in therapy or education 6. References. List your references below and provide telephone numbers where they may be contacted* In providing this information you are consenting to the Department of Human Services or their designee contacting these individuals for reference verification purposes. .