Consent and Release Form

Crimes That May Block Your Employment

Long Term Care Security Act - Title 63 O.S. Section 1-1945 et. seq.

You must be fingerprinted to work with this employer. We will do a national background check and an arrest in any state is reviewed. Your fingerprints will be used to check the criminal history records of the FBI. The FBI will retain your fingerprints and associated information/biometrics and, while retained, your fingerprints will continue to be compared against other fingerprints submitted to, or retained by, the FBI.

If convicted for a crime listed below, you may not be able to work for nursing, assisted living, adult day care, and residential care facilities; homes for the developmentally disabled; group homes; home health and hospice agencies. These crimes apply to nurse aides, activity, social services, kitchen, housekeeping, maintenance and other non-licensed jobs. Licensure Boards define the crimes that apply for licensed health care professionals. Tell this provider if you were fingerprinted for your license. Your arrest history will be monitored. If sentenced for any disqualifying crimes while employed you may lose your job.

You will be found not eligible for aYou will be found not eligible for a job with these employers if you job with these employers if you werewere ever sentenced for one of the following crimes or a related ever sentenced for one of the crime and less than seven (7) years has passed since you completed following crimes or a related crime:1the terms of your sentence, including any period of deferment2: a. abuse, neglect or financial exploitation of any person b. battery, entrusted to the care or possession cindecent exposure and indecent exhibition, except where such of such person, offense disqualifies the applicant as a registered sex offender, b. rape, incest or sodomy, d. pandering, C. child abuse, e. burglary in the first or second degree, d. murder or attempted murder, f. robbery in the first or second degree, e. manslaughter, g.robbery or attempted robbery with a dangerous weapon, or f. kidnapping, imitation firearm, g. aggravated assault and battery, h. arson in the second degree, h. assault and battery with a i. unlawful manufacture, distribution, prescription, or dispensing dangerous weapon, or of a Schedule I through V drug as defined by the Uniform i. arson in the first degree.Controlled Dangerous Substances Act, j. grand larceny, or k. petit larceny or shoplifting.

1 If the results of a criminal history background check reveal that the subject person has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, the employer shall not hire or contract with the person. [63 O.S. 1-1950.1(C1)] 2 If less than seven (7) years have elapsed since the completion of sentence*, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, the employer shall not hire or contract with the person [63 O.S. § 1-

* The law defines "Completion of the sentence" to mean the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole [63 O.S. § 1-1950.1(A5)]

Oklahoma National Background Check Program http://ONBC.health.ok.gov

This form is a provided as a courtesy for the use of employers. Other versions are allowed to meet Title 63 O.S. § 1-1947(H), which requires that an applicant shall provide the employer a government photo identification of the applicant and written consent for the employer to conduct a registry screening and the [Okla. State Bureau of Investigation (OSBI)] to conduct a state and national criminal history record check under this section. The employer shall maintain the written consent and information regarding the individual's identification in their files for audit purposes. It is recommended a copy of the identification be maintained with the applicant's written consent.

EMPLOYER MUST RETAIN THIS SIGNED APPLICANT CONSENT.

Instructions to Applicant: [63 O.S. 1-1945 et. seq.] Evidence of an applicant's consent to a check of state and/or national licensure, certification, abuse, exclusion and offender registries, and fingerprinting for a state and national criminal history records check is required. If you have an active employment history in OK-SCREEN, new fingerprints may not be needed. New registry checks must be done. With your consent, the employer will submit your information through the OK-SCREEN web portal for checks against state and national registries. If you are cleared, and the employer wishes to continue, you will get an email or telephone notice to schedule an appointment for fingerprinting, if required. You will be responsible for a Ten Dollar ($10) processing fee at the time the appointment is scheduled unless the employer elects to pay the fee. You will have ten (10) calendar days to submit your fingerprints or you will be required to start over [63 O.S. § 1-1947(I4)].

Declarations: By signing this form I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the Federal Bureau of Investigation for the purpose of conducting a state and national criminal history records check pursuant to 63 O.S. § 1-1947(H I understand that the results will be shared with the Oklahoma National Background Check Program (ONBCP) operated by the Oklahoma State Department of Health (OSDH I understand that if my criminal history results reveal information that prevents the Department from making a final determination, I will be given notice and will have sixty (60) days to make corrections or additions. If I am unable to make corrections or additions within the sixty (60) days, the Department will either deny me eligibility based on the disqualifying results or advise me they cannot make a determination and notify me of my right to appeal. The notice shall include the reasons I was found not eligible for employment and a statement that I have a right to appeal. [63 O.S. § 1-1947(K)]

I understand that as a condition of employment, I agree to report to the employer immediately upon being arraigned, indicted, convicted, or pleading guilty or nolo contendere to one or more of the criminal offenses applicable to my license, certification, permit or employment class; or upon being the subject of a substantiated finding on a registry as described in this Consent and Release and Title 63, Section 1-1947. I understand an arraignment may also be cause for employment restrictions or termination. [63 O.S. § 1-1947(Q)]

FBI Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint- based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Oklahoma National Background Check Program - http://ONBC.health.ok.gov

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

I understand the OSDH will store the records of an employer's enrolled employees, the results of the screening and criminal arrest records search, and an identifier issued by the OSBI for the purposes of receiving an automatic notification from the OSBI if a subsequent criminal arrest record submitted into the system matches a set of fingerprints previously submitted. When there is a match, the OSBI will notify the Department and the Department will notify the employee. This information is confidential, is not subject to disclosure under the Oklahoma Open Records Act, and shall not be disclosed to any person except for purposes of this act or for law enforcement purposes. I will promptly respond to Department inquiries regarding the status of an arraignment or indictment.

Your employer must submit your name, any aliases, address, former states in which you resided, social security number, and date of birth. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application. PLEASE PRINT CLEARLY. The names used must appear as recorded on your birth certificate or other official record.

I am applying for a volunteer position: Select Volunteer Employee Type in OK-SCREEN

In what other states have you lived after 17 years of age?

My signature acknowledges that I have read, understand and accept the terms and conditions outlined in this form. I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the FBI. Both agencies will conduct a state and national criminal history records check and retain my fingerprints for comparison against other fingerprints submitted to, or retained by, the OSBI or FBI. I received an Attachment to this form: "How to Request My Criminal History Report and Complete, or Challenge the Information."

Oklahoma National Background Check Program - http://ONBC.health.ok.gov

How to Request My Criminal History Report and Complete, or Challenge the Information

Updating Criminal Records - OKLAHOMA

Updating your criminal records must be accomplished through the Oklahoma State Bureau of Investigation (OSBI) or in combination with the State in which the arrest or conviction occurred and the Federal Bureau of Investigation. The Oklahoma National Background Check Program (ONBCP) at the Oklahoma State Department of Health cannot change your criminal records.

CHANGE IN LAW REMOVES FEES FOR

UPDATING RECORD: Effective November 1, 2015, all filing fees and court costs paid by a petitioner to file an expungement request will be returned if the person qualifies for an expungement. The OSBI fee will be waived if the subject of the criminal history record has been granted an expungement under the provisions listed in Title 22 of the Oklahoma Statues The following Certified documents are required to update a criminal record with a final disposition. Without these documents the OSBI cannot update your record.

To request your report, after you have fingerprinted email okscreen@health.ok.gov or call 1-855-584-3550 Note: State law does not allow for the complete removal of an arrest that results in a deferred sentence. The arrest will always be a part of the criminal record and the disposition will be updated to read Pled Not Guilty, Case Dismissed, resulting in no conviction for that arrest. If charges were not filed (you did not go to court nor did an attorney appear in court on your behalf) you must obtain 3 certified documents, exception Oklahoma County and Tulsa County you will only have 2 certified documents. The necessary documents are explained below: A Certified letter must be obtained stating there is no record of the arrest in the files of the County and/or City Court Clerk. The letter must be signed and certified by the County and/or City Court Clerk, and A Certified letter must be obtained from the District Attorney's Office in the county of the arrest. This letter must be written on District Attorney office letterhead and signed by the District Attorney or Assistant District Attorney stating there is no record of the arrest in the files of the District Attorney. If charges were filed (you went to court or were represented in court by an attorney) In addition, when no record exists at the Court Clerk's Office or the District Attorney's Office, a A Certified copy of the final disposition should certified copy of the arrest/incident report relating to be obtained from the Court Clerk's Office in the that arrest must be obtained from the arresting county of arrest. If charges were handled in city court, contact the municipal court in the city of arrest. You may call the automated-attendant line (405) 879-2690 for additional information. If you received a deferred sentence and upon successful completion - Web: https://osbi.ok.gov/criminal-history/update- criminal-history A Certified copy of the deferred dismissal should be obtained from the Court Clerk's Office in the Email: RAP-Sheet-Question@osbi.ok.gov county* of arrest. If the case is no longer on file at the Court Clerk's Office, contact the District Attorney's Office for a certified copy. Oklahoma County & Tulsa County District Attorney's Offices will assist only subject(s) who have received a deferred sentence. *If charges were handled in city court, contact the municipal court in the city of arrest. Oklahoma National Background Check Program - http://ONBC.health.ok.gov

Challenge of a Criminal History Summary - FBI's Criminal Justice Information Services (CJIS) Division

The FBI's Criminal Justice Information

Services (CJIS) Division serves as the nation's central repository and custodian for fingerprints and related Criminal History Summary information. As custodian of such information, the CJIS Division does not have the authority to modify any Criminal History Summary information unless specifically notified to do SO by the agency that owns the information. If you believe your Criminal History Summary contains inaccurate or incomplete information, you have two options for requesting a change or correction: Option 1: Contact the agency or agencies that submitted the information to the FBI. Missing or Incorrect State (Non-Federal) Information Most states, through agreement with the FBI, require that modification requests for Criminal History Summary information be processed through their respective state central repository (State Identification Bureau) before any update can be applied by the FBI to its record. You may contact the respective state repository(ies) for assistance, and, if applicable, request that they provide the FBI with updates to your Criminal History Summary. Contact information for each state is provided here: https://www.fbi.gov/services/cjis/identity-history-

summary-checks/state-identification-bureau-listing

Several states maintain their own record system. Record updates are made at the state level only, SO the FBI cannot modify its records. Instead, the FBI accesses the state's system for authorized purposes to review the record. Contact information for states maintaining records at the state level is provided here: https://www.fbi.gov/services/cjis/identity-history-

Missing or Incorrect Federal Information For federal Criminal History Summary updates, the FBI must receive a request directly from the original arresting agency, from a court with jurisdiction over the arrest data, or from another agency with jurisdiction over the arrest data. Option 2: Electronically submit your challenge request directly to the FBI Step 1: Go to https://www.edo.cjis.gov Step 2: Follow the steps under the "Challenging Your Identity History Summary" section. If you submitted a challenge request electronically directly to the FBI, you will receive a response electronically and an option to receive a response by First-Class Mail via the U.S. Postal Service. Option 3: Send a written challenge request to the FBI's CJIS Division. Your written request should clearly identify the information that you feel is inaccurate or incomplete and should include copies of any available proof or supporting documentation to support your claim. For example, if your disposition information is incorrect or missing, you may submit documentation obtained from the court having control over the arrest or the office prosecuting the offense. The FBI will contact appropriate agencies in an attempt to verify or correct challenged entries for you. Upon receipt of an official communication from the agency with control over the data, the FBI will make appropriate changes and notify you of the outcome. You may submit an Identity History Summary challenge to the FBI by writing to the following address:

summary-checks/state-maintained-records-listing.

Attention: Criminal History Analysis Team 1 1000 Custer Hollow Road Clarksburg, WV 2630 Web: http://www.fbi.gov/about-us/cjis/criminal- history-summary-checks/challenge-of-a-criminal- history-summary

Oklahoma National Background Check Program - http://ONBC.health.ok.gov