Sexual Misconduct Verification System Request Form

Sexual Misconduct Verification System Request Form

This form is being used to replace the Institution Request Form for those needing access to the Sexual Misconduct Verification System through the Oregon Department of Education. If you believe you have an Institution ID, you can search for it on the Institution Lookup Tool. All required sections of this form must be completed entirely. Failure to complete each section or provide any additional required documentation will delay the processing of your request. For questions about this form contact Amanda Leopard at ode.institutions-request@state.or.us. For questions about fingerprinting, contact Stacy Guise at Stacey.Guise@ode.oregon.gov.

Today's Date*

Requests will be processed in the order they were submitted.

Institution ID

If you are requesting a change to a current institution, please provide your institution ID. If you do not know your ID, but know you have done business with ODE previously and believe you have an ID, you can locate it on the Institution Lookup Tool.

Institution Sector*

Select Public, Private, or Private Non-Profit.

Select

Legal Institution Name*

Provide the legal institution name as listed with the IRS.

Institution Name (Doing Business As)

ONLY provide this if the Institution Doing Business As name is something different than the legal name.

Street Address*

Provide the physical location of the institution. Include a full address (e.g. 255 Capitol St. Salem, OR 97310).

Mailing Address

ONLY provide a mailing address if it is different than the street address of the institution. Include a full address (e.g. 255 Capitol St. Salem, OR 97310).

Phone Number*

Provide the institution's main contact phone number (e.g. 503-947-5600).

Fax Number

Provide the institution's main fax number if applicable (e.g. 503-378-5156).

E-mail Address*

Provide the institution's main contact e-mail address (e.g. ode.institutions-request@state.or.us).

Website Address

Provide the institution's website home page address if applicable (e.g. https://www.oregon.gov/ode/).

Employee Information

This information is stored in the Institution Database and these will be the contacts listed on your grant.

Institution Head - Name*

Provide the first and last name of the person considered the head of your institution.

Institution Head - Email Address*

Provide the e-mail address of the person considered the head of your institution (e.g. amanda.leopard@state.or.us).

Institution Head - Phone Number*

Provide the phone number of the person considered the head of your institution (e.g. 503-947-5600).

Submitter's Name*

The name of the person submitting this form. It is not a requirement that the person completing the form be the institution's head, however the person submitting the form assumes responsibility for the information provided.

Submitter's Email Address*

The e-mail address of the person submitting this form. This will be used to contact the submitter with any questions, or to provide the Institution ID number once approved.

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