AGING AND DISABILITY SERVICES ADMINISTRATION

January 22, 2001

AASA No. 01-002

?SUBJECT: Required use of new version Background Inquiry Application Form

Dear Nursing Home/Facility Administrator:

This letter is a follow-up to Dear Administrator letter AASA: No.00-025 in which you were notified of a revision to the Background Inquiry Application Form DSHS 09-828C(X).

This form was revised 10/2000.

The Background Check Centralization Unit has informed us that they will stop processing earlier versions of the inquiry form on February 1, 2001. After February 1, 2001, inquiries submitted on an earlier version of the form will not be processed.

If you need a supply of the new forms (10/2000 version) you can place an order by

faxing your request to the DSHS Forms/Publications Warehouse at (360) 664-0597.? In your fax, please include 1) the facility name and complete mailing address 2) the form name, 3) DSHS form number (found in the lower left hand corner of the form) and, 4) the number requested. (NOTE: The warehouse is limited to sending 200 or fewer copies of each form ordered).

For questions about ordering, please contact the DSHS Forms/Publications Warehouse at (360) 753-1528.

Sincerely,

Patricia K. Lashway, Director

Residential Care Services