LEO Clinic Staff Application

LEO Clinic Staff Application

INSTRUCTIONS: Complete ALL sections in full. Fields marked with * are required. This form must be completed in full before your start date. Falsification of any information may result in termination.
Personal Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Employment History
Position Applied For
Current Employment Status
If currently employed, may we contact your employer?
Current/Most Recent Employer
Education
Highest Degree/Education
Additional Degrees/Certifications (if applicable)
Licenses/Certifications

Per DCF Regulations, copies of all current licenses/certifications must be filed in your personnel record. Provide all that apply.
Licenses and Certifications
Additional Credential Details
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician

First NameLast Name
Practice Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
References
Reference Name

First NameMiddle NameLast Name
Relationship / Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Background Check Disclosure & Authorization

DCF Regulations 17a-20-22(a,b) require criminal background checks through the CT State Police Bureau of Identification and DCF Protective Service background checks through the DCF Hotline for ALL clinic employees, regardless of job duties, before staff may work. LEO Clinic cannot employ anyone convicted within 5 years of a felony against persons; injury/risk of injury to a minor; impairing the morals of a child; or possession, use or sale of a controlled substance.
Have you ever been convicted of any crime?
If yes, please explain (nature of offense, date, jurisdictions, disposition)
Have you ever been listed on the DCF Abuse/Neglect Registry?
If yes, please explain
By signing below, I authorize The Latin Enrichment Organization, LLC to conduct a Connecticut State Police Criminal History Background Check and a Connecticut Department of Children and Families (DCF) Protective Services Background Check. I further authorize the release of any records or information necessary to complete these background checks, as required by DCF Regulations § 17a-20-22.
Required Documents

Per DCF Regulations 17a-20-22 and Connecticut State requirements, all documents listed requested below must be submitted prior to or upon hire.
Current Resume

Cancelof
Government-Issued Photo ID (Driver's License or Passport)

Cancelof
Professional License/Certification (Clinical License, APRN, MD, LPN, etc.)

Cancelof
Completed Pre-Employment Physical Examination (within 12 months) Regulation 17a-20-22 (a)

Cancelof
Tuberculosis (TB) Test Results (within 12 months) Regulation 17a-20-22 (a)

Cancelof
Connecticut State Police Criminal History Background Check (DPS-846-C) — §17a-20-22(a,b)

https://portal.ct.gov/-/media/DESPP/reports_and_records/DPS0846CCriminalHistoryRecordRequestFormRev120117pdf.pdf?la=en&hash=EA50398A227AA13333672A334F53FB6B
Cancelof
DCF / CPS Protective Services Background Check (DCF-3031) — §17a-20-22(a)

https://portal.ct.gov/-/media/DCF/Policy/NEW-fillin-Forms/DCF-3031-Authorization-for-DCF-CPS-BGC-CR-only-Rev-7-2022.pdf
Cancelof
Completed DCF Mandated Reporter Training Certificate — CGS §17a-101

Cancelof
Acknowledgments
Acknowledgments
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

LEO Clinic Staff Application

Personal Information

Employment History

Education

Licenses/Certifications

Emergency Contact

References

Background Check Disclosure & Authorization

Required Documents

Acknowledgments