You are seeking to be placed or are currently in a shared living home. DAIL guidelines require background checks be completed when an adult over the age of 18 lives in a shared living home where another vulnerable individual may reside. Additionally, a disclosure to caregivers of any history that could indicate dangerous behavior or “Peggy's Law Discloser" is required. We request background information and records from Vermont Criminal Information Center, (VCIC or other states), Adult Protective Services (APS), Department of Children and Families (DCF formerly SRS), Department of Motor Vehicles (DMV) and Office of the Inspector General (OIG) as part of the intake process and annually. By completing this requested Background check form, you consent for findings to become a part of your record at GMSS, and to be disclosed to caregivers in the Peggy’s Law Disclosure.

have reviewed the State of Vermont, Agency of Human Services

Background Check Exclusions below and confirm that I do not have any convictions, substantiations or findings as outlined from this policy.

I understand that Green Mountain Support Services will conduct background checks for me now and on an annual

Funds administered by DAIL (including Medicaid) may not be used to employ, place or contract with a person who has: A Substantiated record of abuse, neglect, or exploitation of a child or a vulnerable adult: Been excluded from participation In Medicaid or Medicare services, programs, or facilitates by the federal Department of Health and Human Services" Office of the Inspector General: A criminal conviction for an offense involving bodily injury, abuse of a vulnerable person, a felony drug offense, or a property/money crime involving violation of a position of trust, including, but not limited to:

Larceny, including thefts and robbery

Homicide, including murder or manslaughter

Adult Protective Services, HC 2 South, 280 State Drive, Waterbury, VT 05671-2060

Child Abuse Registry Unit, 280 State Drive, HC 1 North Bldg. B, VT 05671-2401

This form is for use with the ON-LINE registry checking system ONLY

**** This consent form must be filled out completely and signed by the current employee, prospective

employee, contractor or volunteer and kept on file at the requesting organization. The Agency of

Human Services reserves the right to audit these consent forms at any time.

Current or Prospective Employee, Contractor, or Volunteer Information

I hereby authorize release of any information of reports of abuse, neglect or exploitation substantiated against me and contained in the Vermont Adult Abuse Registry and/or the Vermont Child Protection Registryto:

Last Modified: 06/05/2018 8:10 AM

Green Mountain Support Services

CONSENT FOR RELEASE OF INFORMATION REQUEST FOR CRIMINAL RECORD CHECK

It is important to put your FULL LEGAL name

1. Employee or person living in the home of the employee:

herby acknowledge and agree to a check of any criminal record of convictions which may be maintained by the Vermont Criminal Information Center. I understand that the results of that check will be made available to Green Mountain Support Services for use in reviewing my suitability as an employee to consumers. I further understand that I Vermont Criminal Information have the right to appeal the results of the criminal record check to the Center, Department of Public Safety, 103 South Main Street, Waterbury, VT 05871.

(or person living in the home of the employee)

Agency of Transportation dmv.vermont.gov

120 State St Montpelier, Vermont 05603-0001 802.828.2000

All applicable sections of this form (front and back) must be completed to obtain the

requested information. Do not mail cash! Make check or money order payable (in U.S. funds) to: Vermont Department of Motor Vehicles.

All requests must include proof of identification (i.e., copy of your state issued ID For a driver record other than your own please also include documentation proving you are authorized to obtain the requested information. All requests not including required documentation will be returned.

Signature required on back of form.

Mail to (if different than above):

Listing of 1 - 4 current or expired registrations – $8.00 Listing of 1 - 4 current or expired operator’s license – $8.00 Certified copy of current or original registration application – $8.00 Certified copy of expired operator’s license application – $8.00 Certified copy individual accident report – $12.00 Certified copy police accident report – $18.00 Insurance information of accident – $8.00 Statistics and research – $42.00 per hour List of registered dealers, transporters, periodic inspection stations, rental vehicle companies, fuel dealers and distributors (including gallons sold or delivered - $8.00 per page

Periodic inspection sticker record – $8.00 Certified copy of suspension notice – $8.00 Certified copy of reinstatement notice – $8.00 Certified copy of title – $6.00 Certified copy of vehicle title search, title info, lien info. – $22.00 Certified copy of vessel, snowmobile, or ATV title search – $13.00 Certified copy of 3-year operating record (Vermont only) – $14.00 Certified copy of complete operating record (Vermont only) – $20.00

Other – Provide detailed explanation on reverse side. All other forms of information requested provided will be at a minimum of $8.00 per page

concerning(complete as much information as possible):

Specific information requested:

Detailed explanation of intended use(attach additional sheet if necessary):

The information requested may be disclosed if authorized by the Driver Privacy Protection Act. Information being requested is (initialappropriate category below*1):

1. acting on behalf of a government agency in carrying out its functions. (18 U.S.C. §2721(b1

For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person

2. For use in connection with matters of motor vehicles or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts, and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers. (18 U.S.C. §2721(b2

3. For use in the formal course of business by a legitimate business or its agents, employees, or contractors to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors. (18 U.S.C. §2721(b3A If information provided does not match DMV records, correct information will not be provided. DMV will only disclose that information does not match.

4. For use in connection with any proceeding in any court or government agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of any court. (18 U.S.C. §2721(b4

5. For use by any insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating, or underwriting. (18 U.S.C. §2721(b6

6. For use by an employer, of its agent or insurer, to obtain or verify information relating to a holder of a commercial driver's license which is required under the Commercial Motor Vehicle Safety Act of 1996 [Title XII of Public Law 99-570]. (18 U.S.C. §2721(b9

7. Unrestricted or specified use with written consent of the person who is the subject of the information. This includes information regarding oneself ("Authorization of Release" below must be completed in full (18 U.S.C. §2721(b13

8. For any use specifically authorized by law that is related to the operation of a motor vehicle or public safety. (18 U.S.C. §2721(b14

I hereby, with my signature, authorize (name of person or business you are authorizing):

To perform a one-timesearch of the Vermont Department of Motor Vehicles files pertaining to me and any resulting reports. Or

A one-timeauthorization to transact business pertaining to me within the Vermont Department of Motor Vehicles.

In requesting and using this information I acknowledge that this disclosure and any re-disclosure is subject to the Driver Privacy

Protection Act (18 U.S.C. §2723 This is signed and the request is made subject to penalties of 18 U.S.C §2723 and V.S.A. §202.

Driver’s license number of requestor:

Upon receipt of this request by the Vermont Department of Motor Vehicles, it will be reviewed by appropriate personnel to determine whether this request conforms to DPPA protocol and requirements. Failure to meet these qualifications or to provide adequateinformation to make a determination will result in the denial of your request.

DEPARTMENTUSEONLY–DONOTWRITEBEYONDTHIS

This request is hereby denied as the record(s) is/are exempt from inspection and copying for the following reason: They are records which, by law, are designated confidential or by a similar term. They are records which, by law, may only be disclosed to specifically designated persons.

You have the right to appeal this denial to the Commissioner of Motor Vehicles(must be submitted in writing

Vermont Department of Motor Vehicles

DAIL Background Check Policy: Update 2017

DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

Department of Disabilities, Aging and Independent Living (DAIL)

Performing background checks on individuals who may work with vulnerable people is a component

of preventing abuse, neglect and exploitation. This policy provides a consistent framework for

background checks and describes when a background check is required, the elements of a background

check, and what is done if a background check reveals a potential problem.

Background checks supplement but do not replace reference checks. Background checks should never

be relied upon as a substitute for personal contact with former employers or others who are in a position

to have personal knowledge about the prospective worker’s or volunteer’s qualifications to work with

1 A.“Agency” means an organization that operates programs/services administered by DAILfor

any “person who receives services.”

B. “Background check” includes all of the following:

1.Child abuse registrycheck: database maintained by the Department for Children and

Families (“DCF”) to provide information about people who have been substantiated for

abuse, neglect and/or exploitation of children.

2.Adult abuse registrycheck: database maintained by the Department of Disabilities,

Aging and Independent Living(“DAIL”) to provide information about people who have

been substantiated for the abuse, neglect and/or exploitation of a vulnerable adult(s

3.Criminal backgroundcheck: databases, which include the sex offender registry,

maintained byVermont Crime Information Center (“VCIC”);

4.Federal Exclusions Databasescheck: databases maintained by the federal government to

1 This definition also means an organization that operates programs/services for the Vermont Department of Health’s Children’s Personal Care Services. Page 1of 7

DAIL Background Check Policy: Update 2017

include Department of Health and Human Services’ Office of Inspector GeneralList of

Excluded Individuals/Entities (LEIE),System for Award Managementor the Department

5.Motor Vehicle Driver Recordcheck: database maintained by the Vermont

Department of Motor Vehicles.(For volunteers or other workers who transport persons

who receive services as an expected part of the regular job duties

C. “Fiscal/ Employer Agent (F/EA)”means an entity paid by the State to administer payroll

services, including background checks, for individuals enrolled in self-directed services

options. For example, ARIS Solutions is an F/EA.

D. “Individual Employer” means a contracted home provider (e.g. developmental home, shared

living, adult foster care), surrogate, family member or person who receives services who

employs or contracts with a worker.

E. “Long-term care facility”means a residential services setting that is licensed and regulated

by the Division of Licensing and Protection. This includes nursing facilities, residential care

homes, assisted living residences, therapeutic community residences, and intermediate care

facilities for individuals with developmental disabilities (ICF/DD) and homes for the terminally

F. “Person who receives services” means an individual who receives services through a program 2 administered by DAIL, including, but not limited to,

Choices for Care Home-Based Services

Children’s Personal Care Services

Developmental Disabilities Services

Traumatic Brain Injury Waiver Services

Vocational Rehabilitation Services

G. “Volunteer” means an individual, who provides a service, as a result of a formal agreement

with an agency, program or individual employer, but who is not paid (at all or more than just a

stipend or expense reimbursement), and has the opportunity for unsupervised interaction with, or

access to the financial resources of, a person who receives services.

H. “Worker” means an individual who is employed by or contracts with an agency or individual

2 This definition also means an individual who receives Children’s Personal Care Services, a program administered by

DAIL Background Check Policy: Update 2017

III. Background Check Requirements

A. Long-term care facilities are required to conduct background checks as set forth in the

regulations that govern each facility, found at http://dlp.vermont.gov/survey-cert/facility-regs, and are not

subject to the DAIL Background Check Policy.

B. Background checks are requiredfor all prospective workers who are paid with funds

C. Background checks are requiredfor all prospective volunteers.

D. Motor vehicle driver background checks are requiredfor prospective workers and volunteers who would be expected to transport persons who receive services as part of the regular job

duties. It is at the discretion of the employer of record to determine whether to hire a worker, or engage

a contractor or volunteer with a record of motor vehicle violations.

E. Background checks are requiredfor respite workers hired by families through Flexible

Family Funding, the Dementia Respite Program, the National Family Caregiver Support Program

3 F. Background checks are requiredfor all adults who reside in a home, such as a

developmental home or shared living home, when that home receives DAIL funding to provide

residential support to a person who receives services.

G. The agency/ or F/EA shall:

provide a copy of this background check policy to all prospective workers and

volunteers before a background check is conducted; and

conduct background checks required by this policy.

H. The agency or individual employer shall pay for background checks required by this policy;

an F/EA is not responsible for paying these costs. A prospective worker or volunteer shall not be

charged for the costs of background checks required by this policy.

IV. Offer/Start Date of Employment/Contract/Volunteer Opportunity

A. An offer of employment, contract or volunteer opportunity may be made contingent upon satisfactory background checks.

B. No prospective worker or volunteer shall begin work until notified by the employer that the background checks are completed and found to be satisfactory.

C.Medicaid funds shall not be used to pay for services provided before the background 4 check is completed or when the background check is found to be unsatisfactory.

3 “Reside” means intend to remain in the home permanently or for an extended period of time. 4 When the “individual employer” changes for a worker who already provides, and is expected to continue to provide, Page 3of 7

DAIL Background Check Policy: Update 2017

Funds administered by DAIL shall not be used, to employ or contract with a worker who has:

A. A substantiated record of abuse, neglect, or exploitation of a child as determined by DCF;

B. A substantiated record of abuse, neglect, or exploitation of a vulnerable adult as determined by

C. Been excluded from participation in Medicaid or Medicare services or programs, or from

facilities, as reflected in exclusion databases referenced in II B. 4 above.;

D. A criminal conviction, unless a variance has been granted as set forth in Section VI below, 5 which meets the criteria, “job-related” and ‘business necessity” including the following:

• embezzlement
• extortion
• homicide, including murder or manslaughter
• stalking
• cruelty to children or animals
• kidnapping
• possession of child pornography
• arson
• drug-related

abuse, neglect or exploitation of a child or vulnerable adult lewd and lascivious conduct assaults unlawful restraint recklessly endangering another frauds, including forgery larceny, including thefts and robbery burglary

If a prospective worker or volunteer has a criminal conviction(s), which could result in exclusion from employment, he/she must be informed that he/she may apply for a variance as explained below in Section VI. Decisions regarding exclusions from employment or requests for a variance shall be made on a case-by-case basis. .

services to the same “person who receives services,” a new background check is required. Under those circumstances, the worker will not be paid with funds administered by DAIL while another background check is completed, but will be paid retroactively if the background check is satisfactory. 5 The Equal Employment Opportunity Commission (“EEOC”) defines “job-related” and “business necessity.” See www.eeoc.gov/laws/guidance/arrest_conviction.cfm. Based on the job requirements and functions, the criminal conviction(s) must present an unacceptable level of risk for the vulnerable person or employer. Page 4of 7

DAIL Background Check Policy: Update 2017

A.Variances for starting work before a background check is completed will not be considered.

B. The determination whether to grant a variance must be based on a review and consideration of all of the following factors:

nature and seriousness of the offense(s)

time elapsed since the offense(s)

age at the time of the offense(s)

• child or adult protective services

involvement, since the date of the criminal offense, with the criminal justice system and/or

disclosure of the criminal conviction(s) by the prospective worker or volunteer to the

person receiving services, the surrogate, and the legal guardian, if any

prospective worker’s unique caregiving relationship with the person receiving services

unavailability of other workers or volunteers who could reasonably be expected to perform

C. Process for requesting a variance

a. When a prospective worker requests a variance, the agency is responsible for

the decision to grant or deny a variance under this policy. For exclusions see

b. The agency shall issue the decision regarding the variance within 15 business

days of receipt of the request for a variance.

c. The agency shall follow the standards set forth in this policy when granting or

d. The agency shall maintain written documentation of the decision to grant or

deny a variance, including the rationale, listing any conditions. A copy of the

written documentation shall be kept by the agency and made available to quality

a. A contracted home provider (e.g., developmental home, shared living, adult

foster care), surrogate, family member or, person who receives services, who

employs a worker with the use of an F/EA, must submit a variance request in

writing. In addition to the information provided pursuant to Section VI above,

the request must include the following:

i. A variance request letter from the employer, explaining the

circumstances and the reason why it is important that the prospective

worker be a paid caregiver for the person who receives services.

ii. A letter from the prospective worker explaining the conviction(s) and

why he/she should be allowed to be the paid caregiver for the person

DAIL Background Check Policy: Update 2017

b. With the consent of the prospective employee, the request may include a letter

from the case manager of the person receiving services, explaining why he/she

does or does not support the variance.

c. Variance requests submitted by individual employers for Choices for Care, the

Attendant Services Program or the Traumatic Brain Injury (TBI) Services must

Department of Disabilities, Aging and Independent Living

280 State Drive, HC 2 South

Waterbury, VT 05671-2070

Fax: (802) 241-0385

Email: AHS.DAILASDBackgroundChecks@vermont.gov

Variance requests submitted by individual employers for Developmental

Disabilities Services must be submitted to:

Department of Disabilities, Aging and Independent Living

Developmental Disabilities Services Division

280 State Drive, HC 2 South

Waterbury, VT 05671-2030

Variance requests submitted by individual employers for Children’s Personal

Care Services must be submitted to:

Children with Special Health Needs Unit

Children’s Personal Care Services

108 Cherry Street, Box 70

d. The Department shall follow the standards set forth in this policy.

e. The Department retains the right to request additional information to assist in

making a decision regarding a requested variance.

f. The Department shall provide a written decision, within 15 business days of

receipt of the variance request, to the individual employer that includes the

rationale for granting or denying a variance request, any conditions associated

with granting or denying the variance, and appeal rights, if applicable. The

Department shall notify the F/EA, for purposes of accepting timesheets for

processing, only that a variance request has been granted or denied.

g. A copy of the decision regarding the variance request and any supporting

documentation (including the factors considered) shall be kept in the