Background Check Form

It requires that a health facility/agency that is a:

psychiatric facility
hospital that provides swing bed services
ICF/MR
home for the aged
nursing home
home health agency
county medical care facility
hospice

Shall not employ, independently contract with, or grant clinical privileges to an individual who regularly has direct access to or provides direct services to patients or residents in the health facility/agency until the health facility or agency conductsa fingerprint-based criminal history check.

An individual who applies for employment either as an employee or as an independent contractor or for clinical privileges with a health care facility/agency and has received a good faith offer of employment, an independent contract, or clinical privileges shall give written consent at the time of application for the care facility/agency to conduct a criminal history check, and shall give a written statement disclosing that he or she has not been convicted of a crime that would prohibit employment.

NOTE: Throughout this form "employee" includes persons independently contracted with and/or those granted clinical privileges.

Full Name*

First NameLast Name

Facility

License Number

As a condition of being considered for employment:

a. I hereby consent to and authorize the health facility/agency to conduct a background check that includes a search of state and federal abuse and neglect registries and databases, in addition to a fingerprint-based search of state and federal criminal history records. I understand that this consent extends to the release and sharing of such information with the State Departments of Community Health, Human Services, Corrections, and State Police.

b. I hereby authorize the release of any relevant information to the health facility/agency to be used to conduct the background check as required under per state House Bill Rule.

c. I understand, except for a knowing or intentional release of false information, the health facility/agency has no liability in connection with a background check conducted under per state House Bill Rule, or the release of criminal history record information for the purposes of making an employment decision.

d. I understand that the health facility/agency will make the final employment determination. I also understand that the health facility/agency may terminate the background check or determine not to hire at any stage of the process.

e. I understand that the health facility/agency, in denying employment to an applicant, and reasonably relying on information obtained through a background check, is provided immunity from any action brought by an applicant due to the employment decision. I agree to provide the information necessary to conduct a criminal background check.

Signature*

Date

Name*

Middle Name

Last Name*

Alias/Other name used (Maiden)

Suffix

Country of Citizenship*

Place of Birth*

Date of Birth*

Date

Address:

Street address*

Street address Line 2

City*

State/Province*

Postal/Zip Code*

Height*

Weight*

Hair Color*

Eye Color*

Gender*

Race*

Phone Number*

Social Security Number*

Driver License Number*

Conditional Hire Date

Date

Name of State

Has this applicant resided in [NAME OF STATE] continuously for the past 12 months?*

YESNO

License / Certification Number

The following convictions and/or findings may disqualify you from working in long-term care facility/agency:

a. Relevant Crime Described under 42 USC 1320a-7 - 42 USC 1320a-7 is a statutory provision within the Federal Social Security Act which describes a number of crimes for which a conviction will exclude an individual from participation in any federal health care program. The crimes include patient abuse, health care fraud, as well as any crimes related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

b. Felony - Any felony, or an attempt or conspiracy to commit any felony.

c. Misdemeanor - Any state or federal crime that is substantially similar to the misdemeanors described below:

Any misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use of force or violence.
Any misdemeanor for assault if there was no use of a firearm or dangerous weapon and no intent to commit murder or inflict great bodily injury.
Any misdemeanor involving criminal sexual conduct. Any misdemeanor involving abuse or neglect, torture, or cruelty.
Any misdemeanor involving home invasion.
Any misdemeanor involving embezzlement, larceny, fraud, theft or second or third degree retail fraud.
Any misdemeanor involving negligent homicide.
Any misdemeanor involving the possession, use or delivery of a controlled substance.
Any misdemeanor involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance.

d. Any finding of Not Guilty by Reason of Insanity.

e. Any substantiated finding of patient or resident neglect, abuse, or misappropriation of property.

Listed below are all offenses that I have been convicted of, including all terms and conditions of sentencing, parole and probation, and/or any substantiated finding of patient or resident neglect, abuse, or misappropriation of property.

Date of Conviction: City: Sentence: Date of Discharge:

Date of Conviction

Date

Charge

City

State

Sentence

Date of Discharge

Date

I certify that the above statements are correct and complete to the best of my knowledge.

Name*

Signature*

Date*

Date

If the health facility/agency determines it necessary to employ me pending the results of the state and federal criminal history background check, I understand the following:

a. If the background check does not confirm my disclosure statement made above, my employment will be terminated for good cause, unless and until I successfully prove that the disqualifying information is inaccurate, expunged or set aside.

b. If I knowingly provided false information regarding my identity, criminal convictions, or substantiated findings of patient or resident neglect, abuse, or misappropriation of property, I may be guilty of a misdemeanor punishable by imprisonment for not more than93afineofnotmorethan and/or days $500.00.

c. As required by MCL 333.20173a and MCL 330.1134a, I agree that as a condition of continued employment, I shall report in writing to the health facility/agency immediately upon being arraigned on a felony charge or convicted of one or more of the criminal offenses as described in MCL 333.20173a and MCL 330.1134a, or upon becoming the subject of an order or dispositional finding of "Not Guilty by Reason of Insanity", or upon being the subject of a state or federal agency substantiated finding of patient or resident neglect, abuse, or misappropriation of property. Reporting of an arraignment is not cause for termination or denial of employment.

Signature*

Date*

Date

I understand that upon my request, the health facility/agency can provide a copy of any disqualifying record information found on any of the relevant registries or databases.

I understand that if I believe the results of any disqualifying information found on any relevant registry is inaccurate, it is my responsibility to contact the agency that maintains the registry to correct the registry information.

I understand that if I believe the results of the criminal history fingerprint record are inaccurate, or if the conviction contained in the criminal history record is one that may be expunged or set aside, I may file an appeal with the Department of Community Health.

Signature*

Date*

Date

BACKGROUND CHECK FORM

Address: