SCREENING QUESTIONAIRE Rev-12-1-24

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

MonthDayYear
Date
Social Security Number*
Drivers or Non-Drivers License # *
State of Insurance (Enter N/A if you do not have auto insurance)*
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 hereby authorize USA Investigations LLC 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. To determine eligibility for employment. 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 qualified entity with which I am or is seeking to be employed.

Authorized agencies are allowed to release a copy of the state and national criminal record information to a person who requests a copy of his or her own record if the identification of the record was based on the submission of the person's fingerprints. Therefore, if you wish to review your record, you may request a copy from the screening agency. After you have reviewed the criminal history record, if you believe the Florida information is incomplete or inaccurate, you may conduct a personal review as provided in s.943.056, F.S. Title 28 CFR, Section 16.30-34 and Rule 11C-8.001, F.A.C> by calling FDLE at (850) 410-7898. If you believe the national information is in error, you may contact the FBI at (304)625-2000.
Do you authorize the release of your criminal history record to other qualified entities?*

I DoDo Not
Enter name of school
I am a current or prospective: (Check one)*

EmployeeVolunteerContractor/Vendor
Signature*

Clear
Today's Date*

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

MonthDayYear
Date

USA INVESTIGATIONS, LLC

6750 N ANDREWS AVE, SUITE 200

FT. LAUDERDALE, FL 33309

DRUG SCREENING THROUGH URINALYSIS

URINE SPECIMEN COLLECTION PROCEDURAL CHECKLIST
Applicant's Name*
Applicant's Social Security Number*
First Person
Second Person
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.
Type of ID Used*
Identification Number*
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
NOTE: The specimen should remain in full view of both the applicant and the collector until it is sealed.
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 specimen temperature was *
The time from urination to temperature measurement for this specimen was*
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'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