Disclosure Regarding Background Investigation

The Arc of the Capital Area (“The Arc”) may request, for lawful purposes, background information about you from a consumer reporting agency in connection with your partnering with The Arc, including but not limited to employment, independent contractor assignments, interning, and volunteering. This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by The Arc, throughout your employment, contract period, or volunteer time, as applicable.

The Arc will use www.checkr.com via POINT to assemble background checks. The scope of this disclosure is all-encompassing, however, allowing The Arc to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.

The types of information that may be obtained include, but are not limited to: social security number and name verifications, address history, and criminal records and history. Information may be obtained from public or private sources, including government agencies, past employers, etc.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report.

 

Acknowledgment & Authorization for Background Screening

I have read and understand the "Disclosure Regarding Background Investigation" and the "Summary of Consumer Rights Under the Fair Credit Reporting Act."

I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by The Arc at any time after receipt of this authorization and throughout my partnership with The Arc, whether employment, contracting, volunteering, or interning. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Backgrounds Online, Department of Public Safety, The Arc, and any other entity on behalf of The Arc. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. 

Acknowledgment & Authorization for Background Screening

I have read and understand the "Disclosure Regarding Background Investigation" and the "Summary of
Consumer Rights Under the Fair Credit Reporting Act."

I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by The Arc at
any time after receipt of this authorization and throughout my partnership with The Arc, whether employment, contracting, volunteering, or interning. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Backgrounds Online, Department of Public Safety, The Arc, and any other entity on behalf of The Arc. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. 

I acknowledge that I have been informed by The Arc of the Capital Area that a review of the OIG's Cumulative Sanction List will be performed to verify that I have not had state nor federal sanctions imposed for the following Social Security Act violations:

• 1128(a)(l)     Program related conviction
• 1128(a)(2)    Conviction related to patient abuse of neglect 
• 1128(a)(3)    Felony conviction relating to health care fraud
• 1128(a)(4)    Felony conviction related to controlled substance violations 
• 1128(b)(l)     Conviction relating to fraud
• 1128(b)(2)    Conviction relating to obstruction of an investigation 
• 1128(b)(3)    Conviction relating to fraud
• 1128(b)(4)    License revocation or suspension
• 1128(b)(S)    Suspension or exclusion under a Federal or State health care program
• 1128(b)(6)    Excessive claims or furnishing of unnecessary or substandard
                      items or services 
• 1128(b)(7)    Fraud, kickbacks and other prohibited services
• 1128(b)(8)    Entities owned or controlled by a sanctioned individual 
• 1128(b)(9)    Failure to disclose required information
• 1128(b)(lO)   Failure to supply requested information on subcontractors and
                       suppliers 
• 1128(b)(ll)    Failure to provide payment information
• 1128(b)(l2)   Failure to grant immediate access 
• 1128(b)(l3)   Failure to take corrective action
• 1128(b)(l4)   Default on health education loan or scholarship obligations 
• 1128(b)(l5)   Individuals controlling sanctioned entities
• 1128 Aa        Imposition of a civil money penalty or assessment 
• 1156(b)        PRO recommendation

I understand that verification of non-sanctions both at the state and federal levels will be done, by checking OIG data base, at the time of hire and monthly while employed by The Arc of the Capital Area. I acknowledge that ifl am found to be ineligible for participation in state or federal health care programs, that my employment will be terminated immediately. I have informed this agency of all names,(IE, aliases, maiden) , that I have used in the past. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

I understand that The Arc of the Capital Area is a tobacco-free workplace.

1. According to The Arc of the Capital Area’s confidentiality policy, “Information
   pertaining to an individual or family obtained by The Arc of the Capital Area for a particular purpose may not be used or made available for another purpose without consent of that individual or family.”
2. In keeping with this policy, prior to use of a person’s name, likeness, or written or spoken comments in agency materials, the agency must obtain written permission via the Media Consent Form.
3. All Arc of the Capital Area employees and volunteers will be given the opportunity to sign the Media Consent Form during their initial orientation to the agency.
4. The signer may revoke it in writing at any time, except to the extent that the agency has already taken action based on the original permission.
5. The Arc of the Capital Area’s Volunteer Coordinator will maintain all signed Media Consent Forms on file.

 

By selecting the box below, I hereby grant permission for The Arc of the Capital Area to use my Name, Photo/Video, written comments or spoken comments, in informational, promotional, development, and fundraising materials to promote quality programs and community awareness for persons with disabilities.

These materials may include, but are not limited to, newsletters, award nominations, promotional videos, program reports, training documents, volunteer recruitment information, grant proposals, and press releases.

I understand that this consent can be revoked by me at any time except to the extent that The Arc of the Capital Area has already taken actions in reliance on my consent. To effectively revoke this consent, I agree to provide a written statement to The Arc of the Capital Area, 1106 Clayton Lane #215e Austin, TX 78723, indicating my intent to revoke the consent of future use. 

I hereby release and discharge The Arc of the Capital Area and its agents, servants, and employees from all claims, causes of action, and liability arising out of or related in any way to the above-named individual’s participation in The Arc of the Capital Area’s program activities whether on-site or during the course of a field trip. I expressly release, on behalf of myself and/or the Participant, The Arc of the Capital Area and its agents, servants, and employees from liability for any act or omission, including negligence, which results in injuries or damages to the Participant whether on-site or during the court of a field trip. I further indemnify The Arc of the Capital Area for any losses, damages, costs, claims, or attorneys’ fees associated with any injury sustained or caused by the Participant.

Volunteer Handbook Agreement

Please review the Volunteer Handbook prior to signing the agreement below.

 

I  agree to the following:

• Conduct: I agree to maintain confidentiality concerning the circumstances of my client(s) and will abide by the volunteer guidelines and code of conduct outlined in the Education Program Volunteer Training Manual.
• Volunteer Handbook: I have read and understand the contents of the training manual, which includes the following: Volunteer Code of Conduct; Rights and Responsibilities; What are Intellectual and Developmental Disabilities; Volunteering at the Education Program; About the Education Program; The Education Program Volunteer Duties.
• Scheduling: I understand The Arc‘s procedure for scheduling and cancelling volunteer dates. If I need to cancel for whatever reason I will inform The Arc of the Capital Area staff or the Volunteer Coordinator.