BAAS State Registry Consent Form: Form 3655 and NH EASY Filing

The BAAS State Registry Consent Form, officially Form 3655, is a one-page authorization you sign so a New Hampshire employer can check the state’s adult abuse, neglect, and exploitation registry before hiring you. You fill in your identifying details, sign in front of a witness, and your employer sends it to the Bureau of Adult and Aging Care Services. By statute, the department must respond within five business days of receiving the request.¹

When You’ll Be Asked To Sign It

Any employer running a program licensed, certified, or funded by the New Hampshire Department of Health and Human Services must check the registry before bringing on a new employee, consultant, contractor, or volunteer who may interact with clients.¹ That includes nursing homes, home health agencies, residential care facilities, community-based service organizations that receive state funding or hold a state license, and hospitals under DHHS licensing. If a job in one of those settings is in your future, expect Form 3655 to land in your onboarding packet.

The registry itself records founded reports where an investigation found that a paid or volunteer caregiver, guardian, or someone acting under a power of attorney abused, neglected, or exploited a vulnerable adult.² This is a New Hampshire check only and is separate from any federal background screening the employer may also run.

Paper Form or NH EASY?

Form 3655 is a downloadable PDF on the DHHS website under the Bureau of Adult and Aging Care Services State Registry page.³ Most employers keep blank copies on hand. If yours hasn’t given you one, you can print it yourself.

As of November 2025, licensed, certified, or DHHS-funded hospitals, nursing homes, and home care agencies must transition to an automated process through the NH EASY online portal for all new registry checks.⁴ If your employer uses NH EASY, you may not fill out the paper form at all — the system handles the consent electronically, and no witness signature is required because the portal verifies your identity interactively. Employers not covered by that requirement can still submit the paper form by mail or email.

How To Fill Out Form 3655

The form has two sections. Your employer completes the top portion with its own information. You complete the employee section below it.

Legal name. Last, first, and middle name exactly as they appear on your government-issued identification. The form warns that illegible entries will be stamped “Unable to Process” and returned.
Other names. Any maiden names, former married names, or aliases. This lets the registry catch matches under names you may have used in the past.
Mailing address. Current street address, city, state, and zip code.
Date of birth. Required. A missing or inaccurate date of birth is one of the specific reasons the form gets returned as unprocessable.³
Last four digits of your Social Security number. Optional. Under the federal Privacy Act of 1974, no government agency can deny you a right or benefit for refusing to disclose your Social Security number unless a federal statute specifically requires it. Providing it helps distinguish you from someone with the same name and birth date, but leaving it blank will not get your form rejected.⁵
Position and category. Your job title and whether you are a new employee, existing employee, consultant, volunteer, vendor, or other.⁶

Print clearly in dark ink. Don’t use whiteout, don’t cross anything out, and don’t handwrite modifications onto the printed form. If you make a mistake, start with a fresh copy.

Signing and the Witness Requirement

The bottom of the form has signature lines for you, a witness, and (if applicable) a parent or guardian for anyone under 18 or with a legal representative. You sign and date the form, and a witness signs and dates it as well.³

The witness doesn’t need to be a notary. A supervisor, HR representative, or other agency official works. What matters is that someone observes you sign and adds their own signature confirming it. An unwitnessed paper form will be returned; the form itself lists “Not Witnessed” as an explicit rejection reason.

Where the Form Goes

In most cases, your employer submits the completed form rather than you. If you’re sending it yourself, check with your employer first, because they may need to add their information or route the request through NH EASY instead. Paper submissions go to the BAAS State Registry unit:⁶

Mail: BAAS State Registry, 97 Pleasant Street, Concord, NH 03301
Email: BAASStateRegistry@dhhs.nh.gov

For questions about the process, contact the BAAS State Registry at 603-271-8154 or toll-free at 1-800-852-3345, extension 8154.⁴ Neither the form nor the registry page states whether a fee applies, so if you want to be certain before submitting, ask the office directly.

What Happens After You Submit

By statute, the department must notify the employer within five business days of receiving the request. If your name isn’t on the registry, the employer gets a confirmation of that fact. If it is, the notice includes the date you were placed on the registry.¹ Results go to the employer, not to you, and the department does not release registry information over the phone.

Keep a record of the date the form was sent. If the five business days pass without word, you or your employer will want that reference when following up.

Common Reasons the Form Gets Returned

The form itself lists specific reasons BAAS staff will reject a submission without processing it:³

Missing or inaccurate date of birth.
No witness signature on a paper form.
Altered form: whiteout, crossed-out entries, or handwritten modifications to the printed fields.
Illegible entries the staff cannot read.
Copies that are too dark, usually from heavy photocopying. Print a fresh copy of the PDF instead of copying someone else’s blank.

Each rejection adds at least a week once you factor in mail time and resubmission, which matters when a start date depends on clearing the check.

If You Turn Up on the Registry

A match doesn’t automatically end the hire, but the employer cannot bring you on unless the department grants a waiver.¹ Whether the employer pursues one depends on the nature of the finding, the position, and the employer’s own judgment. The employer may ask your permission to obtain the details of the founded report as part of that decision.

If you believe you shouldn’t be on the registry, the statute gives you an appeal. When DHHS places someone on the registry after a founded investigation, it must notify that person within five business days and inform them of the right to contest the finding. You have ten business days from that notice to file an appeal, and you’re entitled to a full administrative hearing. You may hire an attorney at your own expense.¹

If the hearing upholds the finding, you can petition the Merrimack County Probate Court within 30 days of the final order. The court can affirm, reverse, or send the case back, and you carry the burden of showing the department’s decision was clearly unreasonable or unlawful. Separately, the statute allows a person on the registry to petition the probate court to expunge the report entirely.¹

1
New Hampshire General Court. New Hampshire Code 161-F:49 – Registry
2
New Hampshire Department of Health and Human Services. He-E 701 Adult Protection Services Program
3
New Hampshire Department of Health and Human Services. BAAS 3655 Bureau of Adult and Aging Services State Registry Consent
4
New Hampshire Department of Health and Human Services. Bureau of Adult and Aging Care Services State Registry
5
Social Security Administration. Privacy Act of 1974
6
New Hampshire Department of Health and Human Services. BAAS 25-15 PR Revision of BAAS Form 3655 and New Form 3610