Request staff exclusion list 2025

1. Click ‘Get Form’ to open the request staff exclusion list in the editor.
2. Begin by filling out Part 1: Applicant Information. Enter the applicant's first name, middle initial, last name, and date of birth. Specify the job title for which they are being considered.
3. If the applicant does not have a Social Security Number or Alien Registration Number, provide the facility/provider name and address along with selecting the appropriate oversight agency from OMH, OPWDD, DOH, SED, OASAS, or OCFS.
4. Proceed to Part 2: Authorized Person Information. Fill in your name, work email (required), facility/provider name, and phone number.
5. Once all fields are completed accurately, review your entries for any errors before submitting. Use the 'Print Form' option if you need a hard copy for your records.

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