DOH Form 106E Instructions

BACKGROUND

It is the duty and responsibility of the state and of licensed or certified providers to ensure the safety and well-being of vulnerable persons who receive care at state licensed or certified health care facilities, agencies or organizations (provider).  As a result, background checks are required on any person or entity seeking licensure or certification as a healthcare facility, agency or organization.

PURPOSE

Persons or entities seeking an exemption from the finding of a criminal conviction or confirmed abuse for purposes of state licensure or certification shall use DOH Form 106E to request an exemption.  These instructions describe how to complete and submit the Form 106E.

COMPLETION OF THE FORM

  • Complete a separate Form 106E for EACH exemption being requested.  Each criminal record or abuse finding must be submitted on a separate Form 106E.  Multiple findings must not be submitted on a single form.
  • Section I – Individual Seeking Exemption:  Personal information on the individual requesting the exemption is required, including:

Name and signature
Social security number
Date of birth
Home, mailing addresses, and email address
Home, business, or cell telephone numbers

  • Section II – Reasons for Exemption:  Provide full and complete responses to each question and provide supporting documentation as required.  Use additional pages as necessary.

SUBMIT THE FORM

An original, completed and signed form must be submitted to Fieldprint at:

Fieldprint, Inc.
12000 Commerce Parkway
Suite 100
Mt. Laurel, NJ 08054

Individuals completing and submitting the form should retain a copy for their records.

FORM AVAILABILITY

Form 106E may be downloaded from the DOH website at http://health.hawaii.gov/ohca/files/2015/09/OHCA-Form-106E-Request-for-Exemption.pdf.