Notice of Final Fitness Determination

Criminal Records Unit Original Notice Amended Notice

1 Name and Mailing Address of Subject Individual (SI) 2 Date of Birth 3 Social Security Number

4 Position

5 Final Fitness Determination (SI has the right to request a hearing if denied or approved with restrictions.) APPROVED APPROVED with Restrictions (OAR 407-007-0320(5)(c)): DENIED (OAR 407-007-0320(5)(c)) Denial based on crimes: Five-year crime (OAR 407-007-0280) Ten-year crime (OAR 407-007-0280) Permanent crime (OAR 407-007-0280) ASFA crime: child foster homes only (PL 105-89) Denial based on conditions: False statement (OAR 407-007-0290) Unresolved arrest(s) or warrant (OAR 407-007-0290) Deferred sentence, diversion or probation (OAR 407-007-0290) Probation violation (OAR 407-007-0290) Sex offender registration (OAR 407-007-0290) Abuse or protective services history (OAR 461-165-0420) CASE CLOSED (SI must be removed from the job immediately. No right to request a hearing.)

If you are denied or restricted, you may appeal the decision by requesting a hearing. The request must be received by DHS –CRU within 45 days of the date this form was signed. Complete a Hearing Request Form (DHS 299) and mail it with a copy of your DHS Criminal History Request Form (DHS 301) to: DHS-CRU, PO Box 14870, Salem OR 97309-5066 The hearing will be conducted in accordance with OAR 137-003-0501. See OAR 407-007-0330 for more information. If you believe your criminal record is incorrect, you must contact the law enforcement agency that is the holder of the record. Contact information can be found in the instructions included with the DHS Criminal History Request (DHS 301). If you need this form in larger print or in a different format, or if you have questions, call DHS-CRU toll-free at 1-888-272-5545. 6 Name and Mailing Address of AD, Qualified Entity 7 Authorized Designee Name

8 Signature of Authorized Designee 9 Date Signed

DHS 0300 (9/07)