FORM OPWDD 151

Request for MHL 16.34 - Abuse/Neglect History Check: This form must be submitted to OPWDD for all prospective employees and volunteers in the OPWDD system. The form must be submitted by all certified and non-certified programs and registered providers.

The Staff Exclusion List is the first required background check to be completed and needs to occur prior to completing the MHL 16.34 check. Pursuant to OPWDD requirements, the applicant is not permitted to have unsupervised contact until the agency receives the results of the MHL 16.34 check.

The purpose of this form is to request that OPWDD conduct a check of records of substantiated allegations of abuse and neglect that occured or were discovered prior to June 30, 2013 and that involved the applicant. This supplements the check of the "Staff Exclusion List" (SEL) requested from the Justice Center which concerns substantiated abuse and neglect that occured on or after June 30, 2013.

*Fields highlighted in red are required

1. Date Of Submission:

2. Applicant Name:

Last Name	First Name	Middle Initial/Name

2a. Applicant Alias:

Alias or Maiden Name:

2b. Applicant Mailing Address:

Address	City	State	Zip

2c. Applicant Email:

Email:

3. Applicant SSN or
Alien Registration Number:

SSN A# INTERNATIONAL VOLUNTEER. Applicant attests to possessing

neither SSN nor Alien Registration Number.

4. Applicant DOB:
(mm/dd/yyyy)

5. Authorized Person Name:

Last Name	First Name	Middle Initial/Name

6. Authorized Person Email Address:

7. Corp ID/ Provider of Services Name:

8. Program TYPE:

9. Was an SEL Request Submitted:

Yes No *SEL needs to be completed first

Type the characters you see in the picture:

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