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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 ....

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How to fill out the HI DHS 1200 online

The HI DHS 1200 form is essential for individuals seeking an exemption from criminal history record and background check standards. This guide will provide you with comprehensive and user-friendly instructions for completing this form online, ensuring you have the necessary information at hand.

Follow the steps to successfully complete the HI DHS 1200 online.

  1. Click ‘Get Form’ button to obtain the HI DHS 1200 form and open it in your preferred online editor.
  2. In Section I, provide your personal details. Enter your last name, first name, middle initial, signature, social security number, birth date, home address, mailing address, home telephone, and business telephone.
  3. Move to Section II: Reasons for Exemption. Complete all required items. Identify the agency or client you will serve and describe the type of service you will provide.
  4. Explain why you believe an exemption should be granted for your criminal conviction or history of abuse.
  5. Provide details about any circumstances surrounding your criminal conviction or abuse that suggest it is unlikely to happen again.
  6. List significant activities or milestones since your conviction, such as employment or participation in therapy or educational programs.
  7. List references along with their telephone numbers for verification purposes, and indicate your consent for the Department of Human Services to contact them.
  8. Include any other comments you feel are pertinent to your exemption request.
  9. Once you have completed the form, save your changes. You may also download, print, or share the form as needed.

Take the next step in your exemption process by completing the HI DHS 1200 form online today.

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