Application and Background Consent

Application and Background Consent

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Personal Information
Name:*

First NameLast Name
Date:

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Social Security Number:*
Driver’s License / ID:*
State:*
Email Address:*
example@example.com
Have you ever applied for employment with this Agency?*

YESNO
How many hours a week are you available for work?*
Are you legally eligible for employment in the United States?*

YESNO
Position applying for:*

Educational Background:*

	School Name / Location	Major	Yrs of Study/Degree
College / Graduate
Vo-Tech / Trade
High School
Others

Previous Employment

List the last five years employment history, starting with the most recent employer. (2 jobs required)
1. Company Name:*
Telephone:*
From:*

MonthDayYear
To:*

MonthDayYear
Job Title and Describe Work Completed:*
Reason for leaving:*
2. Company Name:*
Telephone:*
From:*

MonthDayYear
To:*

MonthDayYear
Job Title and Describe Work Completed:*
Reason for leaving:*
Two (2) Professional Reference Check
1. Reference Full Name:*
Phone:*
Position Held:*
2. Reference Full Name:*
Phone:*
Position Held:*
Referral Source
Referral Source:*

Internet (Google)IndeedFacebookAgency EmployeeOther
Other:
Reliable Transportation:*
General
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?*

YesNo
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience:
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED:
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I * authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time
Signature:*

Clear
Date:*

MonthDayYear
Background Check Center (BCC) Consent Form
The BCC process applies to any person who is employed to provide care or services: 1) in any capacity, including as an employee, an agent, or an independent contractor, in a nursing facility, home agency, or similar facility licensed pursuant to Chapter 11 of Title 16 of the Delaware Code, or 2) as an employee of a hospice agency, a home care agency, or a personal assistance services agency (home care agency) licensed pursuant to §122(3)(m), (3)(o) and (3)(x) of Title 16 of the Delaware Code working in a private residence, or 3) temporary employment agencies providing individuals to work in the settings identified in 1 and 2 above.

Four (4) different consents are required: one for the criminal history (state and federal), one for the Child Protection Registry, and one for the transmission of drug test results, as required by 11 Del.C. 1142 and 1146.

For purposes of this form, all of these work settings will be called entity/entities all persons or entities hiring a person for work are employers, all persons working will be called employees, regardless of whether self-employed, or employed by another, and the prospective employer will be the employer seeking to vet an employee prior to hiring, or as directed by statute.

Applicant Rights

I understand that upon my request, the DLTCRP will give me a copy of any potentially adverse information associated with me, based on the Applicant Information I have supplied. The Division cannot provide a copy of the Drug Test. Only the employer or prospective employer has that information.

I understand that if I believe the information provided through the BCC is inaccurate, it is my responsibility to contact the agency that maintains the data source to correct the information. I can find out the source of the data on the BCC website, or by contacting DLTCRP at 1-302-577-1406.
Prospective Employee’s Name:*
I. Criminal Background Check

I am seeking employment in an entity that requires that my application be processed through the BCC, 29 Del.C. §7970. The BCC contains information, derived from the State Bureau of Identification, regarding both my State of Delaware and federal criminal history records. I consent to the sharing of my criminal history record with the Division of Long Term Care Residents Protection (DLTCRP) and the prospective employer. I understand that the criminal history information provided to the prospective employer and DLTCRP is strictly confidential and that it may be used solely to determine my suitability for hiring and continued employment. I also understand that if hired, I will be subject to a periodic update of my criminal history (Rap-Back), and I consent to that process.

If I am directed to work in an entity and the entity is not my employer, I consent to the sharing of my criminal history information by my employer with the entity where I am directed to work. If I am a student training in health care services and am directed to work in an entity as part of that training, I consent to the sharing of my criminal history information by the school I am attending with the entity where I am directed to work. If I am directed by my employer to work with a patient in the community, I consent to the sharing of my criminal history information with the patient, or the patient’s surrogate or agent.

I am providing the information in the space below to facilitate the process of securing my criminal history for the BCC. The information I have provided is true and accurate. I have been informed that failure to provide accurate information could result in a civil penalty of not less than $1,000 nor more than $5,000 for each violation.

I hereby grant the employer or prospective employer a full release from liability related to the procurement or evaluation of my criminal history now, or in the future, if additional information is provided through the Rap-Back. I also grant the employer or prospective employer a full release from liability related to the sharing of my criminal history with an entity where I have been directed to work.

I further understand that any employment prior to the receipt of the criminal history record review is conditional and that such conditional employment is limited to 60 days.
Signature:*

Clear
Date:*

MonthDayYear
**A parent/guardian must sign this form if the applicant is a minor.
Parent/Guardian signature:

Clear
Relationship:
II. Child Protection
Have you ever been involved in a substantiated case of child abuse or neglect?*

YesNo
If Yes, please explain:*
If Yes, please explain:
If Yes, please explain:
I hereby authorize the Delaware Department of Services for Children, Youth and Their Families to provide the below named agency/organization with all substantiated cases of child abuse or neglect concerning me contained in the Child Protection Registry. I further release the Delaware Department of Services for Children, Youth and Their Families, its officers and employees from any and all claims arising out of or in any way connected to the release or dissemination of any information concerning me.
Signature:*

Clear
Date:*

MonthDayYear
**A parent/guardian must sign this form if the applicant is a minor.
Parent/Guardian signature:

Clear
Relationship:
Name of agency or organization:
III. Drug Testing

I am required to submit to drug testing as part of the employment process (11 Del.C. §1142 and 1146).

The BCC will electronically transmit the drug test results directly from the testing laboratory to the prospective employer if the testing laboratory is connected to the Delaware Health Information Network (DHIN). If the testing laboratory is not part of the DHIN, the results will be transmitted to the prospective employer directly by whatever method is mutually agreed upon. The drug test results shall be used solely for the purpose of determining my suitability for employment. The prospective employer is required by law to maintain the confidentiality of the results.

I consent to the release of the drug test results to the prospective employer.
Signature:*

Clear
Date:*

MonthDayYear
**A parent/guardian must sign this form if the applicant is a minor.
Parent/Guardian signature:

Clear
Relationship:
IV. Service Letters

As required by the provisions of 19 Del.C. §708 and 11 Del.C. §8563, I hereby authorize the completion of the Delaware Department of Labor, Office of Labor Law Enforcement Service Letter. The letter(s) may be completed by my most recent previous employer or by a health care facility or child care facility employer for whom I worked in the past (5) years or by a current employer.

I consent to the release of the service letter results to the prospective employer.
Signature:*

Clear
Date:*

MonthDayYear
**A parent/guardian must sign this form if the applicant is a minor.
Parent/Guardian signature:

Clear
Relationship:
V. Application Information
DOB:*

MonthDayYear
SSN:*
Name
First Name:*
Middle Name:
Last Name:*
Suffix:
Alias
Alias First Name:
Alias Middle Name:
Alias Last Name:
Alias Suffix:
Alias
Alias First Name:
Alias Middle Name:
Alias Last Name:
Alias Suffix:
Address
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
County:*
Phone Number:*
Email:*
Position
Position Applying for:
Professional License(s)
Prof. License # (CNA/LPN/RN):
Photo ID Information
Driver's License/State Photo ID #:*
Issued by the state of:*
Gender:*
Race: *
Place of Birth:*
Weight:*
Height:
ft.*
in.*
Eye Color:*
Hair Color:*
Send notices to me via (Check one):

US Mail at the address aboveE-mail at the address aboveText message
Text message at this number:
Should be Empty:

Application and Background Consent

Personal Information

Previous Employment

Two (2) Professional Reference Check

Referral Source

General

Background Check Center (BCC) Consent Form

Name

Alias

Alias

Address

Position

Professional License(s)

Photo ID Information

Height: