Fingerprint Form
Information about your fingerprint-based background check:

  1. The Department of Social and Health Services requires that you complete a fingerprint-based background check. These fingerprint-based background checks are required by several state laws, including RCW 43.43.837.
  2. Your fingerprints will be used to check the criminal history records that are kept by the Washington State Patrol (WSP) and the Federal Bureau of Investigation (FBI). Once the fingerprint check is complete, you may obtain a copy of your background check result by completing an Applicant Request for a Copy of Background Check Information form (DSHS 27-110).
  3. If you believe the results of your background check are not complete or are wrong, you have an opportunity to complete or challenge the accuracy of the information as described below.
    1. The background check result notification explains how to correct information that was provided by any of the BCCU reporting sources listed below:
    2. • Applicant Self-Disclosure
      • Department of Corrections (DOC)
      • Department of Health (DOH)
      • Federal Bureau of Investigation (FBI)
      • Washington Courts
      • Washington State Patrol (WSP)
      • Negative Actions: Aging and Long-Term Administration (ALTSA) / Resident and Client Protection Program; ALTSA / Adult Protective Services; Children's Administration / Child Protective Services

      ii. There are two ways to correct information on the FBI Identification Record:

      • Contact the state or federal agency or agencies that provided the information to the FBI; or
      • Send a written challenge request to the FBl's Criminal Justice Information Services (CJIS) Division by writing to the following address:
      FBI CJIS Division
      Attention: SCU, Module D-2
      1000 Custer Hollow Road
      Clarksburg, Wv 26306

      Your written request to the FBI should clearly identify the information that you feel is inaccurate or incomplete and should include copies of any available proof or documents that support your claim. For example, if information about what happened to a criminal charge against you is incorrect or missing, you may submit documentation from the court or the office that prosecuted the offense. The Correspondence Group will contact appropriate agencies to try to verify or correct challenged entries for you. When the FBI receives official communication from the agency with jurisdiction over the matter, the FBI will make appropriate changes and notify you of the outcome. (This process is described in 28 C.F.R. § 16.34.)

      4. The Federal Bureau of Investigation (FBI) Privacy Act Statement is available on the FBI website at

By signing this notification I acknowledge that:

I received a copy of this notice because I am required to have a fingerprint-based background check. The person or entity that requested the background check is required to keep a copy of this signed notice for their records and to return the original notice to me. I will be notified of the result of my background check when the person or entity that requested the background check received the final fingerprint result notification.