BACKGROUND SCREENING QUESTIONAIRE

USA INVESTIGATIONS, LLC

2101 VISTA PARKWAY, SUITE 310

WEST PALM BEACH, FL 33411

DISCLOSURE/AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES-Bacgroun Screening Disclosure

DISCLOSURE

By this document the facility discloses to you that a consumer report or investigative Consumer Report may be obtained for employment purposes as part of our employment screening process and at any time during your employment with our company. This shall authorize the procurement of a consumer report by the facility as part of the employment background screening process. If hired, this authorization shall remain HCL on file and shall serve as an ongoing authorization for the facility to procure consumer report at any time during my employment. The background check company USA Training Academy and Investigative Services will prepare the report for the company. USA training academy and Investigative Services is located at 3951 North Haverhill Road, West Palm beach, Florida 33417 and can be reached by phone at 561-201-8710 or at their internet website address http://www.usa-training.net/

Authorization

I also authorize the procurement of a consumer report for an investigative consumer report and understand that it may contain information about my criminal history, driver's history, mode of living, character and personal reputation. I hear my authorized the release of all information to USA training academy and investigative services. I understand that I have the right to obtain additional disclosure as to the nature and scope of the investigation upon written requests with a within a reasonable period of time and to obtain a copy of the report upon request. This authorization, an original or copy former, shall be valid for this and any future report or update that may be requested.

This authorization and concent shall be valid in origina, fax, or copy form. The following information is requeied by law enforcemment agencies and other entities for identification purposes when checking records. I is confidential and will be used for any other purpose.

** Asummary of Your Rights under the Fair Credit Reporting Act is also being provided to your with this form.
*** California, Minnesota, Massachusetts, Washington State, New York, New Jersey, and Oklahoma Applicants: Please check below to have a copy of your consumer report e-mailed directly to you***

Type option 1
Notice to Maine Applicants: Under Chaper 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a rquest to whether or not an investigative consumer report was requested. If such report was obtained, you may contact The Consumer Reporting Agency and rquest a copy.
Applicant's Name*
Maiden/AKA/Previous*
Social Security Number*
Date of Birth (This will not affect hiring decision)*

MonthDayYear
Date
Drivers License # *
State of Issuance*
Current & Prior Address History: (Please provide your addresses for the past seven (7) years If more space is needed, please enter in the space provided at the end of this application. *
Signature*

Clear
Date*

MonthDayYear
Date

VECHS WAIVER AGREEMENT

AND STATEMENT

(For Criminal History Check)

This form shall be completed and signed by every current or prospective employee and or volunteer.
I hear by authorized (Enter Name of Qualified Entity) Type a label to submit a set of my fingerprints and this form to the Florida Department of Law Enforcement (FDLE) for the purpose of accessing and reviewing Florida and National criminal history records that may pertain to me. I understand that I would be able to receive any national criminal history record that may pertain to me directly from the Federal Bureau of Investigation (FBI). Pursuant to Title 28 Code of Federal Regulation (CFR) section 16.30.-16.34 I could then freely disclose any such information to whom I choose.
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 Quality entity with which I am seeking to be employed or serve as an employee.

I understand, upon request, you may provide me with a copy of the criminal history record report, and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I am aware that procedures for obtaining a change correction, or updating the FDLE or FBI criminal history are set from in F.S.943.056 and title 28 CFR, Section 16.34. 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 and or volunteer.
A national criminal history record check has previously been requested by: (Enter name and address of qualified entity, if not applicable enter NA) *
Year of previous request (Enter name and address of qualified entity, if not applicable enter NA) *
Have you been convicted of a crime?*

I haveI have not
If convicted, describe the crime and the particulars of the conviction (s) ( If not applicable enter NA) *
Do you authorize the release of your criminal history record to other qualified entities?*

I DoDo Not
I am a current or prospective: (Check one)*

EmployeeVolunteer
Signature*

Clear
Print Full Name *
Full Address*
Date of Birth*

MonthDayYear
Date

USA INVESTIGATIONS, LLC

2101 VISTA PARKWAY, SUITE 310

WEST PALM BEACH, FL 33411

DRUG SCREENING THROUGH URINALYSIS

URINE SPECIMEN COLLECTION PROCEDURAL CHECKLIST
Applicant's Name*
Applicant's Social Security Number*
First Person
Second Person
Collector's Name*
Collector's Title*
Collector should initial in the space to the left following completion of each step listed below.
Applicant has been positively identified by the use of a picture ID.*

Clear
Type of ID Used*
Identification Number*
Applicant has completed the Applicant Consent Form.*

Clear
Room where the urine specimen is to be collected has been checked and is private, secure, and free of foreign substances.*

Clear
A toilet bluing agent has been placed in the toilet bowl (to ensure there is no attempt to dilute the specimen with toilet water*

Clear
Applicant has removed all unnecessary outer garments (such as coat or jacket)*

Clear
Applicant has left all personal belongings. (such as a purse or suitcase) outside the collection room.*

Clear
Applicant has been instructed to wash and dry his/her hands while in the presence of the collector and prior to the screen*

Clear
Applicant has been provided with a new and/or unadulterated specimen collection container.*

Clear
Applicant has been instructed about specimen volume requirements for urinalysis (60 ml./2 oz.)*

Clear
Applicant has been informed that while alone in the collection room, he/she is prohibited from running water, flushing the toilet, or handling anything in the room.*

Clear
Applicant has been allowed to enter the collection room. (The collector must stand outside the door and note on this form if he/she hears any unusual activity. If the applicant runs water or flushes the toilet the specimen is invalid and the procedure must begin again from Step 1)*

Clear
NOTE: Should the applicant be unable to provide a specimen at this time, it is recommended that the applicant be given eight (8) ounces of liquid (water, coffee, soft drink) every thirty (30) minutes until a specimen can be produced. The applicant must stay at the collection site until a specimen of sufficient quantity is obtained
Collector has received the specimen from the applicant. (Should the specimen need to be transferred from the collection container to other containers, the applicant will make such transfer while under observation from the collector.) NOTE: The specimen should remain in full view of both the applicant and the collector until it is sealed.*

Clear
Collector has checked to verify that a specimen of sufficient quantity has been collected. NOTE: Should a specimen of insufficient quantity be presented to the collector, that specimen should be discarded, and another specimen collected in a new container.*

Clear
The collector has checked the temperature of the specimen or has taken other precautions to ensure the specimen was rendered at that particular time.*

Clear
The specimen temperature was *
The time from urination to temperature measurement for this specimen was*
Collector has inspected the specimen's color and checked for any signs of contaminants (any concerns should be noted in the selection labeled "Collector's Additional Comments" at the bottom of this form).*

Clear
NOTE: Should there be reasonable suspicion that the applicant tampered with the specimen, the collector should send the specimen to the laboratory for testing and notify the employing agency. The employing agency may want to make immediate arrangements to collect another specimen. The second specimen should be collected under direct observation by an observer of the same gender. Both specimens should be submitted to the laboratory for analysis.
Collector has sealed the container in the donor's presence and has added appropriate identification to the container's outer label.*

Clear
Collector has informed the client that he/she may wash hands.*

Clear
Collector has seen that the specimen is appropriately safeguarded until such time as it is prepared for and delivered to the laboratory.*

Clear
Collector's Additional Comments:

I hereby certify that the collection of the urine specimen for the above-listed applicant followed the procedures as outlined on this form.
Collector's Signature*

Clear
Date*

MonthDayYear
Date

Should be Empty:

USA INVESTIGATIONS LLC