Background Check Permission & Attestation Form

Background Check Permission & Attestation Form

Provide your details and authorize the background investigation for employment.
Applicant/Employee Information
Full Legal Name

First NameMiddle NameLast Name
Other Names Used (Maiden, Alias, Previous Names)
Date of Birth

MonthDayYear
Date
Social Security
Driver’s License or State ID Number
State Issued
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Consent and Signature

DISCLOSUREFirst Rate Caregivers Health (“Agency”) may obtaininformation about you for employment purposes from a third-party consumerreporting agency and/or state-authorized systems.This information may include, but is not limited to: Criminal history records (local, state, and national) Sex offender registry checks Identity verification Employment and/or professional history (if applicable)In accordance with Home Health Agency requirements, anexpanded or national criminal history background check may be required foremployees providing services in client homes.ADDITIONAL REQUIRED SCREENING DISCLOSUREI understand and authorize that the Agency will also conductthe following checks: Indiana Nurse Aide Registry (if applicable) Office of Inspector General (OIG) Exclusion List Sex Offender Registry (State and/or National)These screenings will be used to determine eligibility foremployment or continued employment.AUTHORIZATIONI, the undersigned, hereby authorize First Rate CaregiversHealth and its designated agents to: Obtain my background and criminal history information Conduct initial and, if applicable, ongoing background checks during my employment Verify information provided by me through appropriate sourcesI authorize all individuals, agencies, and organizations torelease such information. FCRA ACKNOWLEDGMENTI understand that: This authorization is provided in accordance with the Fair Credit Reporting Act (FCRA) My written consent is required before a background check is conducted I have the right to request a copy of any report obtained I have the right to dispute inaccurate or incomplete information
Consent and Disclosure
Fee & Payroll Deduction Authorization

I understand and agree to the following: The cost of the background check is $38. The background check will be inititated only after I accept a client assignment. I am responsible for the cost of the background check. My signature authorizes First Rate Caregivers to deduct $38 from my first paycheck as reimbursement for the background check. I understand this authorization is voluntary, the deduction will be made incompliance with applicable wage adn hour laws, and if my employment ends before the deduction is made, I remain responsible for the cost of the background check.
Fee & Payroll Deduction Authorization
Signature
Date

MonthDayYear
Date
For Company Use Only
Date Authorization Received

MonthDayYear
Date
Background Check Requested By

First NameLast Name
Background Check Completed Date

MonthDayYear
Date
Eligibility Status
Reviewer Signature
Comments / Notes
Should be Empty:

Background Check Permission & Attestation Form

Applicant/Employee Information

Consent and Signature

Fee & Payroll Deduction Authorization

For Company Use Only