DSHS 27-110 – Applicant Request for a Copy of Background Check Information Form

Jurisdiction: Country: United States | Province or State: Washington

What is a DSHS 27-110 – Applicant Request for a Copy of Background Check Information Form?

The DSHS 27-110 is the form you use to ask the Washington State Department of Social and Health Services for a copy of your background check information. If you had a background check processed through the state’s Background Check Central Unit (BCCU), this form lets you request the records the state has on file for that check. It is the official way to obtain your own results and related details.

You use this form when an employer or licensing entity asked DSHS to run a background check on you. The BCCU handles checks for many programs that serve children, youth, and vulnerable adults. That includes long‑term care facilities, in‑home care, foster care and adoption, child care and early learning, and various DSHS or affiliated provider roles. If you are the subject of one of those checks, you can ask for a copy of what BCCU reported.

Who typically uses this form?

Applicants, employees, volunteers, contractors, licensees, and caregivers who were screened through BCCU. You may be a home care aide, adult family home staff, child care provider, foster parent applicant, behavioral health worker, or a contractor who works around clients in DSHS-funded programs. If your role required a BCCU clearance, you are the “applicant” for this form’s purpose.

Why would you need this form?

You may want to review the accuracy of your results, see what the agency or employer saw, or prepare to address a record before a job or licensing decision. You might also need documentation for an appeal or reconsideration. If you believe something is wrong or outdated, seeing the exact entry helps you decide next steps. The form also helps you track what was disclosed if you moved between positions or programs.

Typical usage scenarios

• You applied for a role in a licensed long‑term care setting and want to confirm the results.
• You’re renewing a license and want to see what BCCU reported last time.
• You received a notice of a “record found” and want to understand the details.
• You plan to challenge an error and need the document to point to the issue.
• You switched employers within a DSHS‑regulated field and want a copy for your records.
• You were fingerprinted for a program and want to see what was matched and reported.

The DSHS 27-110 is not a general public records request. It is focused on your own BCCU background check file. It is also not the form you use to authorize a new check for an employer. It only requests a copy of information from a check already processed.

When Would You Use a DSHS 27-110 – Applicant Request for a Copy of Background Check Information Form?

Use the form any time you need to see what BCCU reported about you after a background check tied to a DSHS-affiliated role. The best moment is soon after a check is completed or when you receive a decision that references your background. If you receive a letter saying there is a disqualifying or reviewable record, request your copy to understand the base facts. That gives you a clear path to respond or correct errors.

If you work in long‑term care, adult family homes, assisted living, supported living, or in‑home services, you often have recurring checks. Use the form to compare entries across checks and confirm corrections were applied. If you are a child care provider, early learning professional, or an applicant in a youth‑serving program, use the form to see how your juvenile records, civil findings, or licensing actions are reflected. For foster care or adoption processes, the copy helps you understand what licensing staff considered and what you may need to address through documentation.

Business owners and administrators sometimes help workers request copies when a hiring or placement decision hinges on a specific record. While the employer cannot receive an applicant’s copy without authorization, you can authorize release to a named representative if the form allows. If you are a licensing consultant, HR manager, or facility administrator, you should encourage applicants to request their copy when something appears inconsistent. This reduces guesswork and avoids inappropriate disclosure of unrelated records.

Use the form again if you changed your name or corrected your date of birth with an agency and want to verify that BCCU updated its matching. If you completed fingerprinting after a name‑based check and a result changed, request a new copy to see the impact. If you resolved a case in court, expunged or vacated a conviction, or corrected a mistaken identity, request a copy to confirm the update appears in the latest results.

Personal timing matters. If you wait too long, some records may be archived or purged by retention schedules. Requesting while the check is recent helps BCCU locate the right file. If you do not know the exact check date, include the approximate month and the agency or facility that requested it. That information helps the unit find your record.

Legal Characteristics of the DSHS 27-110 – Applicant Request for a Copy of Background Check Information Form

This form is a records release request and a personal authorization. It is not a contract for employment or licensure. By signing it, you authorize DSHS to release your own background check information to you and, if you elect, to a named third party. Your signature confirms your identity and your consent to receive the information. Many state forms include a certification under penalty of perjury that the information you provide is true. Expect to certify your identity and your relationship to the records.

Is it legally binding?

Yes, in the sense that your signed authorization has legal effect. DSHS relies on your attestation and signature to release confidential information. Your signature guides the scope and destination of the disclosure. If the form includes a perjury statement, false statements can carry penalties. Your consent also limits who may receive the records. The agency, in turn, is bound by law to protect confidential information and to disclose only as allowed.

What ensures enforceability?

Identity verification and clear consent are key. The form typically requires enough personal identifiers for DSHS to confirm they are releasing the right person’s records. You may need to include a copy of a government‑issued photo ID or provide data that matches the background check file. The form directs DSHS where to send the copy and whether you allow release to a representative. The agency must follow privacy and dissemination rules when processing your request. Those rules can require redaction of certain sensitive data, protection of third‑party information, and limits on redisclosure.

General legal considerations

• Privacy and confidentiality. Your background check file contains personal information. DSHS will only release it to you or an authorized recipient. If you authorize a third party, the copy may include sensitive data, so choose carefully and provide accurate contact details.
• Scope limits. The copy reflects what BCCU reported for a specific check or time frame. It may not include every record held by other agencies. If a fingerprint match came from state or federal sources, portions may appear in summary form or with reference to originating agencies.
• Redactions. Expect redactions of other people’s identifiers and any information the law protects from disclosure. The copy focuses on your records and the finding.
• Accuracy and challenges. If you believe a record is wrong, you can seek correction with the source agency, such as a state patrol repository or a court. DSHS can correct its report after the source is corrected.
• Retention and timing. Records are kept for set periods. If your check is older, DSHS may have limited information. Provide as many details as you can to help them locate the file.
• Minors and guardians. If the applicant is a minor or an adult with a legal guardian, additional documentation may be required to authorize release. The form should reflect who has authority to receive the records.
• Redisclosure rules. Once you receive your copy, be careful about sharing it. Employers and programs have specific rules for using and storing background information. Keep your copy secure.

The bottom line: your signed request controls the release, and DSHS must protect your information while following disclosure rules. The form is the mechanism that balances your right to access with the agency’s duty to safeguard sensitive data.

How to Fill Out a DSHS 27-110 – Applicant Request for a Copy of Background Check Information Form

Set yourself up to get a complete, timely copy. Use these steps to complete the form accurately.

1) Gather what you need before you start.

• Your legal name as used on the background check.
• Any other names used, including prior last names and nicknames.
• Your date of birth.
• The last four digits of your Social Security number, if requested.
• Your current mailing address, email, and phone number.
• The name of the agency, employer, facility, or program that requested your check.
• The approximate date the check was run. Include month and year at minimum.
• Any known identifiers for the check, such as a confirmation number, facility ID, OCA, or provider number, if you have one.
• A clear copy of your government‑issued photo ID, if the form asks for it.
• If you want a representative to receive the copy, their full name and contact details.

2) Complete the Applicant Information section.

Print your full legal name exactly as it appeared on the background check submission. Add any aliases or prior names. Use separate lines for each name if the form provides them. Enter your date of birth in the format shown on the form. If the form asks for the last four of your SSN, provide them to help match your file. Enter your contact information. List a mailing address where you can securely receive mail. If email is allowed, provide an email you check regularly.

Tip: Use black or blue ink. Write clearly. If you type on a fillable version, review each field for accuracy. Small typos can delay processing.

3) Identify the background check you want copied.

There is often a section for check details. Provide the requesting agency or facility name. If you were hired or vetted by a specific provider, list that provider. If you were licensed or certified, list the license type. Add the approximate date the check was submitted or completed. If you know whether it was name‑based or fingerprint‑based, indicate that. If you have a confirmation number or facility ID, include it. The more you provide, the faster BCCU can locate the correct file.

Examples:

• “Adult family home pre‑employment check, May 2024, Evergreen Care LLC.”
• “Child care background check, fingerprints completed August 2023.”
• “Home Care Aide certification renewal, January 2025.”

4) Choose where and how you want the copy delivered.

Most forms let you choose mail, email, or another secure delivery method. If you pick email, make sure the address is accurate and accessible only to you. For mail, confirm your mailbox is secure and that your name is on it. If the form allows release to a representative, there will be a space to list their name, relationship, and contact details. Only designate a representative if you truly want them to receive your information.

If you authorize a representative, read any warnings about redisclosure. Your representative will see your personal information. Make sure they will store it securely.

5) Provide identity documentation if required.

Some requests require a copy of your ID. Acceptable IDs usually include a driver license, state ID, passport, or similar government‑issued ID. If you submit a copy, make sure it is legible and not expired. If the form instructs you to present ID in person or to a notary, follow those steps exactly. If a notary section is present, do not sign until you are in front of the notary.

6) Review any disclosures and privacy notices.

The form may include a statement about how your information will be used and stored. There may be a brief summary of your rights to review or challenge records. Read it. If there are checkboxes to consent to email transmission or to authorize a third‑party recipient, make sure your choices match your preferences. Some forms require you to initial next to specific statements. Initial where indicated.

7) Sign and date the form.

Sign using the same name shown in the Applicant Information section. Use ink if submitting a paper copy. Date the form. If the form includes a perjury statement, your signature certifies that the information is true and correct. Unsigned forms are not processed. If someone is signing on your behalf under a legal authority, they should complete any section that documents that authority and attach supporting paperwork.

8) Attach any required documents.

Attach your ID copy if requested. If you are authorizing a representative, attach any required release or proof of authority. If the form invites you to provide supporting details to help locate your check, attach a brief note with those details. Keep your attachments in the order the form specifies.

9) Submit the form as instructed.

The form will list submission options, such as mail, fax, or secure email. Follow those instructions. If you send by mail, consider using a trackable option. If you send by email or fax, confirm the transmission was successful. Do not send the form to the employer or facility; send it to the unit identified on the form.

10) Track processing and follow up if needed.

Processing times vary. If you have a deadline, submit early. If you do not receive a response within the expected timeframe, follow up using the contact method listed on the form. Have your name, date of birth, the requesting agency name, and the approximate check date ready. Do not submit multiple duplicate requests unless directed. Duplicate submissions can slow processing.

11) Review the copy you receive.

When your copy arrives, read it carefully. Check your personal information for accuracy. Review any listed criminal history, civil adjudications, license actions, or negative actions. Note whether entries are labeled as convictions, non‑convictions, pending matters, or findings by a licensing entity. Compare the copy to any notice you received from an employer or licensing program.

12) Decide on next steps, if any.

• If the copy looks accurate, store it securely for your records.
• If you find errors, identify the source agency for the record. For criminal history, that may be the state repository or a court. For licensing findings, contact the licensing unit that issued the decision. Correct the source record first. Then ask BCCU about updating your background check results once the source change is confirmed.
• If an employer decision is pending, share only what you choose to share, or what the program requires, keeping privacy rules in mind. If you authorized the employer as your representative, they may already receive the copy directly.

Helpful completion tips

• Provide the most complete set of names you have used. Name variations are a common cause of mismatch.
• If you had multiple checks in a short window, describe each one with dates and programs. Ask for the specific check you need.
• Use the exact facility or program name used in your application. If the facility has multiple locations, list the location tied to your check.
• If your address changed since the check, make sure you list your current address for delivery.
• Keep a copy of the completed form and everything you sent. Note the date you submitted.

What not to include

• Do not send original identity documents unless the form explicitly requires that and you are using a secure method.
• Do not include unrelated personal records.
• Do not write sensitive data in margins or outside designated fields.

By following these steps, you give DSHS what it needs to locate your file and send you a complete copy. That copy is your best tool to verify accuracy, plan your response to any findings, and keep your professional records organized.

Legal Terms You Might Encounter

• Applicant means you, the person asking for a copy of your background check. On this form, you identify yourself and authorize the agency to release your record to you.
• Background check is the review of records about your criminal history and related data. This form requests a copy of what the agency has on file from that review.
• Authorization is your permission for the agency to release your information. By signing this form, you allow the agency to send your background check copy to you.
• Disclosure is the act of sharing your background check data. The agency discloses the information to you once it confirms your identity and processes the request.
• Criminal history record is the official record of arrests, charges, and outcomes. Your copy may include both convictions and certain non-conviction data as allowed by law and policy.
• Non-conviction data refers to arrests or charges that did not result in a conviction. Your copy may show some non-conviction items, but some may be limited or redacted.
• Redaction means sensitive details are removed or masked. Your copy may show blacked-out information to protect other people’s privacy or confidential sources.
• Name-based check uses your name, date of birth, and other identifiers to find records. If your background check was name-based, your copy reflects those matched records.
• Fingerprint-based check uses your fingerprints to match records. If your background check used prints, your copy reflects that higher-confidence match.
• Aliases or former names are other names you have used, such as a maiden name. Listing all former names helps the agency find and confirm the correct records for your copy.
• Unique identifiers include details like your date of birth or the last digits of your number. The agency uses them to confirm your identity and avoid mismatched records.
• Adverse action is a negative decision based on background results, such as denial of a position. This form does not make decisions; it only requests your copy, but you may use it to understand any decision you received.
• Correction or challenge means asking to fix errors in your record. After you receive your copy, you can use the instructions provided to dispute inaccurate entries.
• Verification is the process the agency uses to confirm you are the person requesting the copy. Expect to provide identifying details, and possibly proof of identity, to complete this step.
• Retention refers to how long the agency keeps your records and your request. Your copy is for your use; the agency retains its records under its own schedule and rules.

FAQs

Do you have to provide identification with your request?

You should expect to provide enough information to verify your identity. Some programs accept a completed form with personal identifiers. Others may ask for a copy of a photo ID, or for you to answer verification questions. Follow the instructions on the form and any cover page you received.

Do you need to list every former name you have used?

Yes. Include all former legal names, nicknames used on official documents, and maiden names. Omitting a name can cause an incomplete search and a partial copy. List names with accurate spellings and any known variations.

Do you need fingerprints to get your copy?

Usually, no. Most copy requests rely on your name and identifiers to locate your record. If your original background check used fingerprints, the copy will reflect that. You do not need to submit new fingerprints unless the instructions require them.

Do you have to pay a fee for the copy?

Often, no fee is charged to receive your own copy. Some programs may charge for additional copies or special delivery. If a fee applies, the form or instructions will state the amount and payment method. Do not send payment unless directed.

Do you receive the copy by email or by mail?

Delivery methods vary. Many programs can send a secure electronic copy or mail a paper copy. On the form, you may be asked to pick your delivery method and confirm your email or mailing address. Choose one method and make sure your contact information is current.

Do you need to submit a separate request for each background check?

If you had multiple checks with different programs or positions, you may need separate requests. The form requests a copy of the background information held by the agency for you. If you are unsure which check you need, note the position or program name on the form.

Do you have to request the copy within a deadline?

You can request your own copy at any time. If you are responding to a recent decision, act quickly. Prompt requests help you review the same data that informed the decision. If the form mentions any timeframes, follow them.

Do you need to explain why you want the copy?

No. You have the right to request a copy of your own background check information. You do not need to state a reason. Providing context, like a position title or program name, can help the agency find the correct file.

Do you get to see everything in the background check?

You will receive the information the agency can release to you under its rules. Some details may be redacted to protect others’ privacy or confidential sources. Your copy should still show the key items used in your background clearance.

Do you need to share the copy with an employer or licensor?

You may, but you control your copy. If an employer or program needs results directly, they should request them through their channel. If you choose to share your copy, remove sensitive identifiers before sending, where appropriate.

Checklist: Before, During, and After the Form

Before signing: Information and documents you need

• Your full legal name as it appears on government ID.
• All former names and spellings you have used.
• Date of birth and current contact information.
• The program or position tied to the background check, if known.
• The timeframe when the background check was completed, if known.
• A secure email address and/or current mailing address for delivery.
• A valid photo ID, if the instructions call for a copy.
• Any request or tracking numbers you received earlier.
• A pen with dark ink if you will sign by hand.
• Access to a scanner or camera if you will submit electronically.

During signing: Sections to verify

• Verify your name, former names, and date of birth match your ID.
• Confirm your current mailing address and email are accurate and readable.
• Check that phone numbers include area codes and are correct.
• If there is a box to select delivery method, choose only one.
• Review any boxes authorizing release and initial where required.
• Confirm the program or position reference, if included, is precise.
• Sign and date the form exactly as instructed.
• If notarization or witness is required, complete that step as directed.
• If attaching ID, blur unrelated numbers only if allowed; keep the name and photo clear.
• Review for completeness. No blanks where an answer is required.

After signing: Filing, notifying, storing

• Submit the form through the channel listed on the instructions.
• If mailing, use a secure envelope and track delivery.
• If uploading, confirm the file format and size meet requirements.
• Save a clean copy of the completed form for your records.
• Record the submission date and any confirmation number.
• Set a calendar reminder to follow up if you do not receive a response.
• Store your copy of the background check in a secure location.
• If you spot errors in your copy, prepare your correction request promptly.
• Notify the requesting program only if they ask you to share your copy.
• Update your contact information with the agency if it changes before you receive the copy.

Common Mistakes to Avoid

• Leaving out former names or misspelling them
• Missing names cause incomplete searches. Your copy may omit relevant records and delay your review. Don’t forget to list every former name, with correct spellings and variations.
• Using an outdated mailing or email address
• Outdated contact details lead to undelivered or delayed copies. You’ll wait longer and may need to resubmit. Don’t forget to confirm your current address and test your email inbox.
• Skipping the signature or incorrect dating
• Unsigned or undated forms cannot be processed. Your request will be returned or denied. Don’t forget to sign and date in the correct fields, and use the correct date format.
• Selecting multiple delivery methods
• Choosing more than one option can create confusion and delays. Your copy may be held pending clarification. Don’t forget to pick one method and complete that section fully.
• Sending a hard-to-read ID image
• Blurry or cropped identification can fail verification. Processing stalls until a clear copy arrives. Don’t forget to provide a sharp, well-lit image that shows your name and photo clearly.
• Submitting the form to the wrong office
• Misrouted requests do not reach the background check unit. You lose time and may need to resend. Don’t forget to follow the submission instructions on the form or cover page.
• Assuming the copy will fix a denial automatically
• The copy helps you understand results, but it does not change decisions. You must use the correction or appeal process. Don’t forget to read the instructions that come with your copy.

What to Do After Filling Out the Form

1. Submit the form using the stated method. If mailing, use a trackable service and keep the receipt. If submitting online or by email, confirm you receive a successful upload or send notice.
2. Note your submission date and any confirmation number. Create a simple log with the date, the method used, and any contact details you interacted with. This helps with follow-up and timelines.
3. Watch your email and mail for the copy. Check your spam or junk folder. If you chose mail, allow standard delivery time. Delays can occur if the agency needs to verify your identity.
4. If the agency asks for more information, respond quickly. Provide any missing identifiers or a clearer ID image. Quick responses keep your request moving without falling back in the queue.
5. Review your copy carefully when it arrives. Confirm your name and identifiers are correct. Check each listed event for accuracy: dates, charges, and outcomes. Note any items you do not recognize.
6. If you find an error, follow the correction steps provided with your copy. You may need to submit a written challenge, supporting documents, or certified court records. Keep your tone factual and include specific corrections you seek.
7. If you received a recent decision based on the background check, compare the copy to that decision. Ensure the dates and items match. If they do not, contact the decision-maker and ask what record they used.
8. Decide whether to share your copy. If a program needs an official result, they may need to obtain it directly. If you share your copy, remove unnecessary personal numbers before sending. Use secure delivery.
9. Store your copy in a safe, private place. A locked file or encrypted drive is best. Avoid sharing your full date of birth or other sensitive identifiers unless necessary.
10. Track the lifecycle of your background clearances. Some programs require periodic rechecks. Set reminders for renewal dates, if applicable. Keep your copy handy for reference if you are asked about prior results.
11. If you move or change contact details before you receive the copy, update the agency. Provide both old and new information so your file can be located quickly. This prevents lost mail and returned emails.
12. If you need an additional copy later, submit a new request. Follow the same steps and reference your prior request date if you have it. Do not rely on third parties to send you a copy they received.
13. If your copy reflects sealed or restricted items, do not attempt to unseal them. The redactions exist to protect privacy or due to rules. If you need clarification, use the contact details provided with your copy to ask general questions.
14. If your copy appears incomplete, verify whether you omitted a former name or timeframe. You can submit an updated request containing any missing identifiers. Clarify that you are seeking a comprehensive copy.
15. If your background check relates to multiple positions or programs, label your stored copy by date and program. This helps you avoid confusing different result sets. Keep each copy separate and clearly named.
16. Maintain a short summary for your records. Include the date of the copy, delivery method, and whether any corrections were requested. This summary helps if you are asked about your background status later.