Tennessee Department of Children's Services Waiver Agreement and Statement for Criminal History Checks

This form must be completed and signed by every current or prospective employee, volunteer, contractor/vendor, and foster/adoptive parent for whom criminal history records are requested by a qualified entity.

I hereby authorize AGAPE to submit a set of fingerprints through the TBI vendor and this form to the Tennessee Bureau of Investigation (TBI), for the purpose of accessing and reviewing Tennessee and national criminal history that may pertain to me directly from the FBI, pursuant to 28 CFR, Sections 16.30-16.34. By signing this Waiver Agreement, it is my intent to authorize the dissemination of any national criminal history record that may pertain to me to the Qualified Entity with which I am or am seeking to be a child care provider (employee, volunteer, contractor or foster/adoptive parent.)

I understand that, until the criminal history background check is completed, you may choose to deny me unsupervised access to entity locations. I further understand that, upon request, you will provide me with a copy of the criminal history background report, if any, you receive on me and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I may obtain a prompt determination as to the validity of my challenge before you make a final decision about my status as an employee, volunteer, contractor, or foster/adoptive parent.

A national criminal history background check on me is being requested by AGAPE, 4555 Trousdale Drive, Nashville, TN 37204.

I have been given a copy of the Applicant's Policy Rights (following):

NONCRIMINAL JUSTICE APPLICANT'S PRIVACY RIGHTS

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.

• You must be provided written notification¹ that your fingerprints will be used to check the criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act Statement should explain the authority for collecting your information and how your information will be used, retained, and shared.²
• If you have a criminal history record the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.
• The officials must advise you that the procedures for obtaining a change, correction or update of your criminal history record are set for that Title28, Code of Federal Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record.³

You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.4 

If agency policy permits, the officials may provide you with a copy of your FBI Criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks

If you decide to challenge the accuracy or completeness of your FBI criminal history record you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBl will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBl will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See28 CFR 16.30 through 16.34.)

1. Written notification includes electronic notification, but excludes oral notification. 
2. https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3. See 28 CFR 50.12(b) 
4. See 5U.S.C.552a(b);28U.S.C.534(b);42U.S.C.14616,ArticlelV(c);28CFR20.21(c),20.33(d)and906.2(d).

 

Authorized governmental and non-governmental agencies/officials that conduct a national fingerprint-based criminal history record check on an applicant for a noncriminal justice purpose (such as employment or a license, immigration or naturalization matter, security clearance, or adoption) are obligated to ensure the applicant is provided certain notice and other information and that the results of the check are handled in a manner that protect the applicant's privacy. These obligations are pursuant to the Privacy Act of 1974, Title5, United States Code (U.S.C. Section 552a, and Title 28, Code of Federal Regulations (CFR), Section 50.12, among other authorities.

• Officials must provide to the applicant written notification 1 'that his/her fingerprints will be used to check the criminal history records of the FBI.
• Officials must ensure that an applicant receives, and acknowledges receipt of, an adequate Privacy Act Statement when the applicant submits his/her fingerprints and associated personal information.²
• Officials using the FBl criminal history record (if one exists) to make a determination of the applicant's suitability for the employment, license, or other benefit must provide the applicant the opportunity to complete or challenge the accuracy of the information in the record.
• Officials must advise the applicant that procedures for obtaining a change, correction, or update of an FBI criminal history record are set forth at 28 CFR 16.34.
• Officials should not deny the employment, license, or other benefit based on information in the criminal history record until the applicant has been afforded a reasonable time to correct or complete the record or has declined to do so.
• Officials must use the criminal history record solely for the purpose requested and cannot disseminate the record outside the receiving department, related agency, or other authorized entity.³

The FBl has no objection to officials providing a copy of the applicant's FBI criminal history record to the applicant for review and possible challenge when the record was obtained based on positive fingerprint identification. If agency policy permits, this courtesy will save the applicant the time and additional FBl fee to obtain his/her record directly from the FBl by following the procedures found at 28CFR16.30 through16.34. It will also allow the officials to make a more timely determination of the applicant's suitability.

Each agency should establish and document the process/procedures it utilizes for how/when it gives the applicant notice, what constitutes "a reasonable time" for the applicant to correct or complete the record, and any applicant appeal process that is afforded the applicant. Such documentation will assist State and/or FBl auditors during periodic compliance reviews on use of criminal history records for noncriminal justice purposes.

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1. Written notification includes electronic notification, but excludes oral notification.
2. See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3. See 5U.S.C.552a(b); 28U.S.C.534(b); 42U.S.C.14616, ArticlelV(c) ;28CFR20.21(c) ,20.33(d) ,50.12(b) and 906.2(d).

Check the "Forms" Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.