FORM OPWDD 151

Request for MHL 16.34 - Abuse/Neglect Historyy 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 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.

1. Date Of Submission:

2. Applicant Name:

Last Name	First Name	Middle Initial/Name

3. Applicant SSN or
Alien Registration Number:

SSN A# INTERNATIONAL VOLUNTEER. Applicant attests to possessing

neither SSN nor Alien Registration Number.

4. Applicant DOB:

5. Authorized Person Name:

Last Name	First Name	Middle Initial/Name

6. Authorized Person Email Address:

7. Provider of Services Name:

8. Is the Provider a Registered Provider?:

Yes No ( note that Registered Providers are required to submit requests for MHL 16.34 checks.)

9. Program TYPE:

10. Applicant IS:

Prospective Employee
Prospective Volunteer
"Deemed" Employee

11. Was an SEL Request Submitted:

Yes No

12. Was A CBC Request Submitted, or Will One be Submitted?

Yes No

Proceed to FORM 152