DEPARTMENT OF HUMAN SERVICES

Social Services Division

Adult and Community Care Services Branch

Criminal Conviction Record Check Standards or

Protective Services Central Registry Check Standards

CHECKLIST FOR EXEMPTION REQUEST

The appropriate DHS designee review panel shall consider a request for exemption from the Division’s Criminal Conviction Record Check Standards or Protective Services Central Registry Check Standards only upon the receipt of the documents listed below. The panel shall then have forty-five (45) days to complete its review and to issue its decision on the request.

This checklist, with blocks checked off to confirm the inclusion of the appropriate documents, should accompany the documents submitted to the Department. The request should be forwarded to the DHS designee by the prospective employer agency. The individual should keep copies of all submitted documents for his/her records.

Form DHS 1673, “REQUEST FOR EXEMPTION (From Criminal Conviction Record Check Standards or Protective Services Central Registry Check Standards”.

Must be completed and signed by individual requesting the exemption. A separate DHS 1673 shall be submitted for EACH exemption being requested.

2.	Money order payable to Fieldprint for $25.00

Must submit a money order payable to Fieldprint for $25.00 in order for the exemption request to be processed.

State Name Check Report from eCrim, if applicable.

This is the State name check from Hawaii Criminal Justice Data Center (HCJDC), and it must include the conviction for which the exemption is being sought.

Statement of Authenticity.

This is a statement completed and signed by the individual requesting the exemption that validates the copy of the Hawaii Criminal Justice Data Center (from eCrim) report that is submitted.

Letter from the Prospective Employer Agency.

This letter will confirm the individual’s status as a prospective direct service (or direct contact) provider. The letter must identify the individual and the position for which the individual is being considered.

Job Description.

This description must come from the prospective employer agency. It will help the review panel to determine the relationship of the conviction to the direct services position offered to the individual.

7.	Evidence of Rehabilitation.

Some examples of what may be submitted include: Letters from employers, letters confirming the termination of probation or parole, letters from a professional counselor or clergy with whom the applicant has a professional working relationship, letters indicating completion of self-help program, such as anger management, drug treatment, etc. Letters from relatives and friends are not evidence of rehabilitation.