WATCH Report- Student Request Form

Student Affairs
200 University Parkway, BHH 317
Yakima WA 98901

Phone: 509-249-7724 Fax: 509-249-7909
Washington State Patrol (WSP) WATCH Report-Student Request Form

Request for Criminal History Information-Child/Adult Abuse Information Act RCW 43.43.830 Through 43.43.845
Applicant of Inquiry

Please provide as much information as possible; name and date of birth are mandatory.
Applicant Last Name:*
Applicant First Name:*
Applicant Middle Name:*
Enter N/A if you do not have a middle name.
Alias/Maiden Name(s)- Last:
Alias/Maiden Name(s)- First
Alias/Maiden Name(s)- Middle
Date of Birth:*

MonthDayYear
Sex:

MaleFemale
Race:
Secondary dissemination of this criminal history record information response is prohibited unless in compliance with the statute.
Purpose of this WATCH Form:*

EmploymentStudent Clinical Rotations
Indicate Site that is requesting WSP report
Have you ever been convicted of a crime and/or released from confinement following a conviction related to theft, fraud, violence, and/or drug manufacture or distribution? If yes, please give date, place and nature of each such conviction on a separate piece of paper and attach it to the application. Such conviction(s) may be relevant if job related, but is not an automatic bar from employment/rotation. Arrest or charges that have been expunged do not need to be disclosed.*

YesNo
If "Yes" please explain:
Have you ever had findings made against you in any civil adjudicative proceeding? *

YesNo
If "Yes" please explain:
By signing this form I acknowledge that Pacific Northwest University of Health Sciences has permission to run a Washington State Patrol (WSP) Request for Criminal History Information and Child/Adult Abuse information request. I also acknowledge that completion of this form is official notification of an inquiry being made to WSP.
Signature*

First NameLast Name
Date*

MonthDayYear
No, I would not like a copy of the WSP criminal history reportYes, I would like a copy of the WSP criminal history report
I acknowledge that by pressing the submit button, I am officially signing this document. My typed name below is my symbol and intent of authentication where I willingly signed, understand, and adopt this document.
Should be Empty:

Washington State Patrol (WSP) WATCH Report-Student Request Form

Applicant of Inquiry