Disclosure Statement for Licensed Private Provider Employees
Please complete this form to provide required disclosures as an employee of a licensed private provider under DBHDS regulations. A criminal history background investigation is required by law (37.2-416 (B,(i)), Code of Virginia) on each individual who was not an employee or service provider at the facility prior to July 1, 1999.
Full Name
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First Name
Middle Name
Last Name
Position/Job Title
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Email Address
*
example@example.com
Social Security Number:
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Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Licensed Provider Business Name: Happy Home
Licensed provider Number: 8432
In Virginia or any other location: Have you ever been or are the subject of a founded complaint of child abuse or neglect?
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Yes
No
If yes, please provide details
Have you ever been convicted* of or are you the subject of pending charges for any offense, including moving traffic violations, but excluding offenses before your eighteen birthday which were finally adjudicated in a juvenile court or a youth offender law? Convictions include all adult convictions as well as Virginia juvenile adjudication's for the following: capital murder, first and second degree murder, lynching, or aggravated malicious wounding, if you were fourteen (14) to eighteen (19) when charged)
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Yes
No
If yes, please explain
*If convicted of misdemeanor assault and battery, were any of these convictions committed while employed in a direct consumer care position?
Yes
No
Date of Disclosure
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Month
-
Day
Year
Date
I hereby certify that all entries on this disclosure statement are true and complete. I agree and understand that: (1) any falsification of the information provided, regardless of the time of discovery, may result in termination of my services as an employee: and (2) the information on the disclosure statement is subjective to verification.
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Submit Disclosure
Submit Disclosure
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