Please submit any supporting documentation with the attestation form including a copy of the background check letter indicating the type of crime s on record by 52S4R6

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									                                      AGING AND DISABILITY SERVICES ADMINISTRATION
                                           Attestation Form
                      Request For Exception to Rule For Disqualifying Drug Crimes
SECTION I – THIS SECTION TO BE COMPLETED BY THE EMPLOYEE
FULL NAME                                           TITLE/ROLE                                         DATE OF BIRTH


Type of facility where employee works:        Adult Family Home            Boarding Home          Nursing Home
NAME OF FACILITY                                                                         COUNTY


ADDRESS OF FACILITY                                                             CITY                 STATE       ZIP CODE


SECTION II – THIS SECTION TO BE COMPLETED BY THE ATTESTER
All information in this section must be provided by the attester based upon his/her personal knowledge
(supervised/observed) of care provided in a licensed or contracted working environment. Write N/A (not applicable) for
areas that do not apply.
FULL NAME                                                         TITLE/ROLE


Provide two telephone numbers where you can be reached between 8:00 a.m. and 5:00 p.m. weekdays.
TELEPHONE NUMBER (INCLUDE AREA CODE)                              ALTERNATE TELEPHONE NUMBER (INCLUDE AREA CODE)


What is the best time to call during those hours?
1. How do you know the person named above in Section I?
   I am/was this person’s   Employer      Supervisor                 Other (Only Upon Department Approval)
                                                                                          Yes     No
2. Is this person 18 years of age or older?

3. Is this person your family member or spouse/domestic partner?

4. Has this person worked in the facility full-time continuously for at least 24 months?
PLEASE RATE THE EMPLOYEE IN THE FOLLOWING AREAS AND PROVIDE ADDITIONAL COMMENTS:
                                                                                BELOW                  ABOVE
                                                                    POOR       AVERAGE     AVERAGE    AVERAGE     EXCELLENT

5. Employee’s ability to meet the physical and emotional
   needs of residents.
COMMENTS:



6. Employee’s ability to treat residents with respect, courtesy
   and patience through every aspect of communication with
   residents.
COMMENTS:



7. Employee’s ability to respect residents’ decisions,
   choices, dignity and rights.
COMMENTS:



8. Employee’s ability to reasonably accommodate each
   person’s individual needs and preferences.
COMMENTS:




DSHS 15-418 (REV. 08/2010)
9. Employee’s reliability and integrity.
COMMENTS:



10. Employee’s ability to follow procedures, guidelines, and
    instructions.
COMMENTS:



11. Does this person have a good record of work and attendance?                 Yes        No

12. Please describe why you are requesting an exception to rule for this person.



13. Please indicate the specific drug crime(s), when it occurred, the drug(s) in question and what the employee has done
    to mitigate the situation (attach supporting documentation).



14. Please describe why this person should be allowed to continue providing care to vulnerable adults.



SECTION III – THIS SECTION TO BE COMPLETED BY PROVIDER (ADULT FAMILY HOME) OR ADMINISTRATOR (BOARDING
HOME/NURSING HOME)
FULL NAME                                                             TITLE/ROLE


ADDRESS                                                                             CITY                   STATE        ZIP CODE


NAME OF FACILITY                                                                            COUNTY


ADDRESS OF FACILITY                                                                 CITY                   STATE        ZIP CODE


I certify that the information above is true and correct to the best of my knowledge. I am aware that the employee named in
this document has a disqualifying crime and have made a determination that the person has the character, suitability and
competence to work with vulnerable adults. I am therefore requesting an exception to rule so that this person can continue to
work in the facility. I understand that, as with all of my employees when they are on duty, I am responsible for the employee
actions or inactions that may have a negative or potentially negative impact on a resident or residents.
SIGNATURE                                                                                                     DATE


What supporting documentation must be submitted?                      Where to send the form and supporting documentation.
Please submit any supporting documentation with the attestation       The completed form, a cover letter and supporting documentation
form including a copy of the background check letter indicating the   must be submitted to the attention of RCS Division Director at:
type of crime(s) on record, documentation indicating successful
completion of all court-ordered programs and restitution, and other   Joyce Pashley Stockwell, Director
relevant documentation. The department may request additional         Residential Care Services
information. Failure to provide the required information may result   DSHS/Aging and Disability Services Administration
in a denial of an exception. The department will not accept the       PO Box 45600
Attestation if it is not complete and not notarized                   Olympia, WA 98504-5600
                 State of                                    County of
                 I certify that I have examined the document(s) presented by the above-named individual, that the above-
 NOTARY PUBLIC




                 listed document(s) appear to be genuine and correct copy of documents in the possession of:

                                                        Dated:
                           (Seal or Stamp)
                                                                                            SIGNATURE
                                                        Title :
                                       My appointment expires:

DSHS 15-418 (REV. 08/2010)
Why must this form be completed?
This form must be used when making a request to the Residential Care Services (RCS) Director to grant an exception to
rule for the following disqualifying drug crimes:

Violation of the imitation controlled substances act (VISCA); Violation of the uniform controlled substances act (VUCSA);
Violation of the uniform legend drug act (VULDA); or          Violation of the uniform precursor drug act (VUPDA).

These rules are specified in the following Washington Administrative Codes (WAC); Adult Family Homes – WAC 388-76-
10180, Boarding Homes – WAC 388-78A-2470, Nursing Homes – WAC 388-97-1820.

RCS will review the information submitted to determine if the individual will be granted an exception. The decision will be
made on a case-by-case basis and after carefully considering many factors to ensure safety and needs of vulnerable
adults. Factors such as the home’s compliance history will be considered, as well, when making the decision whether or
not an exception can be granted.

Background Information
Washington state regulations have been expanded to include certain disqualifying drug crimes. Some individuals, who
have previously passed the background check required by RCW, may now be affected by the new regulations.

Important: These rules affect everyone who is required to have a background check no automatic grandfathering
provisions exist in these rules. Please be aware that such an individual may petition the courts to have the crime
“expunged” from their record.

Who may request an exception to rules?
Only the Provider (for Adult Family Homes) or Administrator as the Licensee’s Designee (for Boarding Homes and
Nursing Homes) can request an exception to rule. If the Department approves the request, the exception will be granted
to the person who made the request, not the employee for whom the request is made. If the employee moves to another
facility or another Long Term Care program, the exception will not follow the employee and they will not be able to be
hired if they may have unsupervised access to residents. The person making the request is fully accountable for the
employee’s actions on the premises of the facility.

For whom is the request made?
The request is made for an employee of an Adult Family Home, Boarding Home, or Nursing Home. This person must be
a current employee who has been continuously employed by the same home for at least 24 months in a full-time position.
The employee must be 18 years of age or older. A separate submission of documents is required for each exception
request. For example, if a Provider or Administrator is requesting an exception to rule for two employees, two separate
documentation packets must be submitted.

For whom will the exception not be granted?
The department will not grant an exception to rule for the following individuals with a disqualifying drug crime.
Provider/Licensee (including a spouse, domestic partner, or any partner), Administrator, Officer, Director or majority
owner.

                                           Instructions for filling out the form

Section I – This section is filled out by an employee who has a disqualifying drug crime on their record.

Section II – This section is filled out by the Attestor, the person who directly supervises the employee with a disqualifying
drug crime record and who is not a family member or spouse/domestic partner of the employees. In a smaller facility, the
Attestor may also be the Provider or Administrator. The person who completed Section II must have personal knowledge
of the employee’s caregiving experience that has been achieved after the age of eighteen. Personal knowledge means
that the person has actually observed care provided by the employee and is aware of the personal and professional
qualities of that employee. If the Attestor is a family member or souse/domestic partner of the employee, another credible
person who is familiar with the employee’s caregiving experience must provide the attestation.

Section III – Provider (for Adult Family Homes) or Administrator as the Licensee’s Designee (for Boarding Homes and
Nursing Homes) must sign this section certifying that they will take full responsibility for the employee’s actions at the
home.

DSHS 15-418 (REV. 08/2010)

								
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