BACKGROUND SCREENING QUESTIONAIRE

USA INVESTIGATIONS, LLC

6750 N ANDREWS AVE, SUITE 200

FT. LAUDERDALE, FL 33309

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 Investigations will prepare the report for the company. USA Investigations is located at 6750 North Andrews Ave, Ft. Lauderdale, Florida 33309 and can be reached by phone at 954-778-3932 or at their internet website address http://www.usainvestigations.us/

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.
Nombre Del Solicitante*
Apellido De Soltera o Nombre Anterior*
Número De Seguro Social*
Fecha de nacimiento (Esto no afectará la decisión de empleo)*

MonthDayYear
Date
Número de licencia de conducir*
Estado del seguro de automóvil (ingrese N/A si no tiene seguro)*
Historial de direcciones actual y anterior: (Proporcione sus direcciones de los últimos siete (7) años. Si necesita más espacio, ingrese en el espacio provisto al final de esta solicitud.*
Firma*

Clear
la fecha de hoy*

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.
Por la presente autorizo a USA Investigations LLC. a enviar un conjunto de mis huellas digitales y este formulario al Departamento de Aplicación de la Ley de Florida (FDLE) con el fin de acceder y revisar los registros de antecedentes penales nacionales y de Florida que puedan pertenecerme. Para determinar la elegibilidad para el empleo. Al firmar este Acuerdo de exención, tengo la intención de autorizar la difusión de cualquier antecedente penal nacional que pueda pertenecer a mí a la entidad calificada en la que estoy o busco trabajar.

Las agencias autorizadas pueden revelar una copia de la información de antecedentes penales estatales y nacionales a una persona que solicita una copia de su propio registro si la identificación del registro se basó en la presentación de las huellas digitales de la persona. Por lo tanto, si desea revisar su registro, puede solicitar una copia a la agencia de evaluación. Después de haber revisado el registro de antecedentes penales, si cree que la información de Florida está incompleta o es inexacta, puede realizar una revisión personal según lo dispuesto en s.943.056, F.S. Título 28 CFR, Sección 16.30-34 y Regla 11C-8.001, F.A.C> llamando al FDLE al (850) 410-7898. Si cree que la información nacional es errónea, puede comunicarse con el FBI al (304)625-2000.
¿Autoriza la divulgación de sus antecedentes penales a otras entidades calificadas?*

SiNo
Ingrese el nombre de la escuela
Soy actual o potencial: (Marque uno))*

Empleada/EmpleadoVoluntaria/VoluntarioContratisto / Vendedor o Contratista / Vendedora
Firma*

Clear
la fecha de hoy*

MonthDayYear
Date
Escribe su nombre completo *
Escribe su dirección completa*
Fecha de nacimiento*

MonthDayYear
Date

USA INVESTIGATIONS, LLC

6750 N ANDREWS AVE, SUITE 200

FT. LAUDERDALE, FL 33309

DRUG SCREENING THROUGH URINALYSIS

URINE SPECIMEN COLLECTION PROCEDURAL CHECKLIST
Nombre del solicitante*
Número de Seguro Social del Solicitante*
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.*
Applicant has completed the Applicant Consent Form..*
Type of ID Used*
Identification Number*
Room where the urine specimen is to be collected has been checked and is private, secure, and free of foreign substances.*
A toilet bluing agent has been placed in the toilet bowl (to ensure there is no attempt to dilute the specimen with toilet water*
Applicant has removed all unnecessary outer garments (such as coat or jacket)*
Applicant has left all personal belongings. (such as a purse or suitcase) outside the collection room.*
Applicant has been instructed to wash and dry his/her hands while in the presence of the collector and prior to the screen*
Applicant has been provided with a new and/or unadulterated specimen collection container.*
Applicant has been instructed about specimen volume requirements for urinalysis (60 ml./2 oz.)*
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.*
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).*
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.
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
The collector has checked the temperature of the specimen or has taken other precautions to ensure the specimen was rendered at that particular timer*
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).*
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.*
Collector has informed the applicant that he/she may now wash there hands*
Collector has seen that the specimen is appropriately safeguarded until such time as it is prepared for and delivered to the laboratory.*
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