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Address
Can you meet the requirements of the job?*
Have you worked using a different name?*

WORK HISTORY

Address
Address
Address

Personal References

Address
Address
Address

Educational Background

Graduated
Graduated
Drug tests in the work place are being given; do you object to taking this test?

Have you ever been convicted of: (mark all that apply):

Crimes of violence against persons including but not limited to assault and battery, rape or armed robbery?
Crimes against property including but not limited to burglary and vandalism?
Crimes of dishonesty including but not limited to forgery, passing bad checks, embezzlement?
Crimes of or connected to use/or traffic in drugs and alcohol, including but not limited to drunk driving, possession and use of banned substances?
ALL INFORMATION ON THIS APPLICATION IS TRUE AND CORRECT. YOU HAVE MY PERMISSION TO CHECK ANY AREA OF THIS APPLICATION. YOU HAVE MY PERMISSION TO DO A CRIMINAL BACKGROUND CHECK ON ME.
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Telephone Reference Check

I give permission for my personal information to be released.
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Health Care Worker Background Check

Authorization and Disclosure for Criminal History Records Information (CHRI) Check
I hereby authorize the Illinois Department of Public Health (the Department), the Department's designee, educational entities that train and/or test health care workers. Staffing agencies, my current or potential) employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information relative to the existence or nonexistence of any criminal record. Which it might have concerning me, to any initiator/requestor solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records relating to me, including but not limited to a local unit of government in any State, to release those records to the ISP, FBI. or the Department. I authorize the Department to provide any health care facility, training program. or staffing agency. To which I have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the FBI CHRI. I certify that the ISP, FBI, any entity that maintains criminal records, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that a educational entity or health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer If I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25)
l understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering. if discovered after employment. training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.
l understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.
Name
Address
Gender
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Race
Have you ever had an administrative finding of Abuse, Neglect or Theft?
Have you ever been convicted ora criminal offense other than a minor traffic violation (do not Include convictions that have been expunged, sealed or adjudicated delinquent)?
I certify that the above is true and correct and give my consent for my name to appear on Department's Health Care Worker Registry with the results of my criminal history records check.
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As the parent or guardian of the above named individual who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.
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Max. file size: 500 MB.