PHMC CRIMINAL HISTORY, CHILD ABUSE HISTORY & FBI CLEARANCE REQUEST

Candidate Demographic Information

As of July 1, 2008, prospective childcare service employees are required to submit a federal criminal record check through the FBI as a condition of employment. Prospective employees are currently required to submit a record check for child abuse record checks through DPW and for state criminal record checks through the PA State Police.

Requirements for Employees Servicing Children: Child care service is defined in section 6303 of the Child Protective Services Law as “child-day care

centers, group and family day-care homes, foster homes, adoptive parents, boarding homes for children, juvenile detention center services or programs for delinquent or dependent children; mental health, mental retardation, early intervention and drug and alcohol services for children; and other child-care services which are provided by or subject to approval, licensure, registration or certification by the Department of Public Welfare or a county social services agency.

Requirements for Other Persons Having Contact With Children: Act 176 of 2006 amended section 6344.2 of the Child Protective Services Law to state that prospective

employees applying to engage in occupations with a significant likelihood of regular contact with children, in the form of care, guidance, supervision or training must obtain clearances as a condition of employment. These individuals, including but not limited to social service workers, hospital personnel, counselors, librarians and doctors are required as of July 1, 2008 to obtain an FBI clearance along with their PA State Police Criminal History Check and PA Child Abuse Record Check as a condition of employment.

Instructions:
• Complete attached FBI fingerprint application.

• Forward completed application to HRCredentialing@phmc.org for processing.

• Once processed, FBI Registration receipt will be forwarded to applicant and hiring manager.

• The following documents must be presented at the fingerprint site:
   o  FBI Registration receipt (contains the confirmation number and payment code)
   o Current, valid and unexpired State or Federal photo ID

• You will be registered to be fingerprinted at a location closest to your home address. Additional locations and hours fingerprinting sites can be found at www.Identogo.com

• Results will be forwarded to employee’s home within approximately 2 weeks.

• Original results must be forwarded to the attention of the HRCredentialing@phmc.org,  immediately upon receipt.

FBI Clearance results must be received by HR Credentialing Team prior to first day of employment.

Applicant Registration and Information Form

This form does not need to be turned in at the fingerprint site. It is designed only as a tool to help facilitate your registration for fingerprinting services.

***Please Print Legibly*** All fields required in order to complete registration.

Investigative Consumer Report:

Public Health Management Corporation may request an investigative consumer report about you from HireRight, LLC (“HireRight”), a consumer reporting agency, in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews), the most common form of which is checking personal or professional references through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

If the Company hires you or contracts for your services, the Company may obtain additional consumer reports and investigative consumer reports about you without asking for your authorization again, throughout your employment or your contract period, as allowed by law.

Please see the “Additional State Law Notices” for California, Massachusetts, Minnesota, New Jersey, New York, and Washington that are provided below, as applicable. A California disclosure and summary of your rights under California Civil Code Section 1786.22, and a copy of New York Article 23-A, are being provided to you separately.

Summary of Rights under the Fair Credit Reporting Act:

A summary of your rights under the Fair Credit Reporting Act is being provided to you separately.

San Francisco Fair Chance Ordinance Official Notice:

A copy of the San Francisco Fair Chance Ordinance Official Notice is being provided to you separately.

Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx

I acknowledge that I have received and carefully read and understand the separate “Disclosure and Authorization Regarding Background Investigation for Employment Purposes”; and the separate “Summary of Rights under the Fair Credit Reporting Act” that have been provided to me by the Company. I also acknowledge receipt of and that I have carefully read and understand (as applicable), the separate California Disclosure and Summary of Rights under California Civil Code Section 1786.22; the separate New York Article 23-A; and the separate San Francisco Fair Chance Ordinance Official Notice that have been provided to me.

By my signature below, I authorize the preparation of background reports about me, including background reports that are “investigative consumer reports” by HireRight, and to the furnishing of such background reports to the

Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment or engagement for services (including independent contractor or volunteer assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may, as allowed by law, obtain from HireRight (or from a consumer reporting agency other than HireRight) additional background reports pertaining to me, without asking for my authorization again, throughout my employment or contract period.

I understand that if the Company obtains a credit report about me, then it will only do so where such information is substantially related to the duties and responsibilities of the position in which I am engaged or for which I am being evaluated.

I understand that information contained in my employment (or contractor or volunteer) application, or otherwise disclosed by me before or during my employment (or contract or volunteer assignment), if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.

I understand that the information included in the background reports may be obtained from private and public record sources, including without limitation and as appropriate: government agencies and courthouses; educational institutions; and employers. Accordingly, I hereby authorize all of the following, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal, state and local government agencies and courts; educational institutions (public or private); testing agencies; information service bureaus; credit bureaus and other consumer reporting agencies; other public and private record/data repositories; motor vehicle records agencies; my employers; the military; and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my: employment and earnings history; education, credit, motor vehicle and accident history; drug/alcohol testing results and history; criminal history; litigation history; military service; professional licenses, credentials and certifications; social security number verification; address and alias history; and other information.

Please also note the following:

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by the consumer reporting agency during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the actual copying costs, by appearing at the consumer reporting agency’s offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. The consumer reporting agency has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. “Proper identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, the consumer reporting agency may require additional information concerning your employment and personal or family history to verify your identity.

HireRight, LLC (“HireRight”) will prepare the background report for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761. Information about HireRight’s privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

 

 

MASSACHUSETTS: Upon request to the Company, you have the right to know whether the Company requested an investigative consumer report about you and, upon written request to the Company, you have the right to receive a copy of any such report. You also have the right to ask the consumer reporting agency (e.g., HireRight) for a copy of any such report.

MINNESOTA: You have the right in most circumstances to submit a written request to the consumer reporting agency (e.g., HireRight) for a complete and accurate disclosure of the nature and scope of any consumer report the Company ordered about you. The consumer reporting agency must provide you with this disclosure within 5 days after (i) its receipt of your request or (ii) the date the report was requested by the Company, whichever date is later.

NEW JERSEY: You have the right to submit a request to the consumer reporting agency (e.g., HireRight) for a copy of any investigative consumer report the Company requested about you.

NEW YORK: You have the right, upon written request to the Company, to be informed of whether or not the Company requested a consumer report or an investigative consumer report about you. Shown above is the address and telephone number for HireRight, the consumer reporting agency used by the Company. You may inspect and receive a copy of any such report by contacting that consumer reporting agency. A copy of Article 23-A of the New York Correction Law is also provided below.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written request made to the Company within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You are entitled to this disclosure within 5 days after the date your request is received or the Company ordered the report, whichever is later. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

                               Education Verification Form

Please submit copies of degree and or transcripts with this completed form

Required by the Child Protective Service Law 23 Pa. C.S. Section 6344 (relating to employees having contact with children; adoptive and foster parents) I swear/affirm that, if being hired on a provisional basis, I have applied for certification through ChildLine, the Pennsylvania State Police, and the Federal Bureau of Investigation and am submitting a copy of the appropriate completed request forms to the employer, administrator, supervisor or other person responsible for employment decisions. I swear/affirm that, if providing certifications that have been obtained within the preceding 60 months, I have not been disqualified from employment as outlined below or have not been convicted of an offense similar in nature to a crime listed below under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth. I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law. I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statutes or equivalent crime under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth. Chapter 25 (relating to criminal homicide)

Section 2702 (relating to aggravated assault) Section 2709.1 (relating to stalking) Section 2901 (relating to kidnapping) Section 2902 (relating to unlawful restraint) Section 3121 (relating to rape) Section 3122.1 (relating to statutory sexual assault) Section 3123 (relating to involuntary deviate sexual intercourse) Section 3124.1 (relating to sexual assault) Section 3125 (relating to aggravated indecent assault) Section 3126 (relating to indecent assault) Section 3127 (relating to indecent exposure) Section 4302 (relating to incest) Section 4303 (relating to concealing death of child) Section 4304 (relating to endangering welfare of children) Section 4305 (relating to dealing in infant children) Section 5902(b) (relating to prostitution and related offenses) Section 5903(c) (d) (relating to obscene and other sexual material and performances) Section 6301 (relating to corruption of minors) Section 6312 (relating to sexual abuse of children), or an equivalent crime under Federal law or the law of another state.

I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance, drug device and cosmetic act) committed within the past five years. 2 11/3/15 I understand that I must be dismissed from employment if I am named as a perpetrator of a founded report of child abuse within the past five (5) years or have been convicted of any of the crimes listed above. I understand that if I am being hired on a provisional basis, I am not permitted to work alone with children and must work in the immediate vicinity of a permanent employee during this provisional employment period. I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying employment or participation in a program, activity or service under the Child Protective Services Law as listed above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database. I understand that if the person responsible for employment decisions or the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds for denying employment or participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the person responsible for employment decisions or administrator of a program, activity or service shall immediately require me to submit current certifications obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation. The cost of certifications shall be borne by the employing entity or program, activity or service. I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third degree and shall be subject to discipline up to and including termination or denial of employment. I understand that certifications obtained for employment purposes may be used to apply for employment, serve as an employee, apply to volunteer and serve as a volunteer. I understand that the person responsible for employment decisions or the administrator of a program, activity or service is required to maintain a copy of my certifications. I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code.

hereby, depose and say that I am applying to

provide services to children through Public Health Management Corporation, and I understand that my services will bring me into regular contact with children. I hereby swear or affirm that I have not been disqualified form employment or service under Pennsylvania’s

Child Protective Services Law, 23 PA.C.S & 6344 ( c ), and have not been convicted of an offense similar in nature to a crime listed in 23 PA.C.S & 6344 ( c ), under the laws and former laws of the United States or one of its territories or possessions, another state, District of Columbia, the Commonwealth of Puerto Rico, or a foreign nation, or a former law of the Commonwealth of Pennsylvania.

I understand that this form will be kept by the organization listed above in its ordinary course of business and may be transmitted by that organization to the Philadelphia Department of Human Services, the Commonwealth of Pennsylvania, or other governmental authorities who may rely on the information it may contain. 

I further understand that falsification of the statements herein are grounds for immediate

discipline, including dismissal by the organization listed above, and the statements herein may also be subject to penalties of 18 Pa. C. S. & 4904 relating to unsworn falsification to authorities.