By signing this form, I consent to registry screening and submission of my fingerprints to the Kentucky State Police (KSP) for forwarding to the Federal Bureau of Investigation (FBI) for a state and national criminal history records check and understand that the results will be shared with the Kentucky National Background Check Program operated by the Cabinet for Health and Family Services, Office of Inspector General. I understand that providing fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of my application. My fingerprints and associated information may be retained and compared against other fingerprints submitted to or retained by authorized state and federal systems. I authorize the Kentucky State Police to retain my fingerprints, process future searches against them, and notify the Cabinet for Health and Family Services of subsequent arrests or convictions for use in determining eligibility for employment or licensure. My Social Security Number is requested to keep records accurate where other people may have the same name and birth date. My signature acknowledges that I have read, understand, and accept these terms and conditions.

Facility/Employer: Good 2 B Home Adult Day Healthcare, LLC | Employer Address: 1920 Stanley Gault Parkway, Louisville, KY 40223

Please provide additional history if needed to cover all seven years.

I understand that information requested regarding gender, race, height, eye color, hair color, weight, place of birth, citizenship, and date of birth is used solely for identification and accurate gathering of criminal-history record information and will not be used to discriminate against me in violation of law. I understand that a false statement on any part of this form is grounds for not hiring me or for termination after employment begins. I consent to release of criminal-history information about me by the Kentucky State Police, Federal Bureau of Investigation, and authorized agents. I certify that, to the best of my knowledge and belief, all statements I provided are true, correct, and complete.

I authorize Good 2 B Home Adult Day Healthcare, LLC and Kentucky's KARES/KY National Background Check Program to obtain and review my identity, criminal-history, abuse and neglect, registry, exclusion, and credential information for employment eligibility. I certify that the information I provided is true and complete. I understand that omissions or false statements may result in withdrawal of an offer or termination, and I agree to promptly report later criminal charges or eligibility changes.

I authorize Good 2 B Home Adult Day Healthcare, LLC, as the qualified entity, to request submission of my fingerprints to the Kentucky State Police and Federal Bureau of Investigation for access to and review of state and national criminal-history records that may pertain to me. I authorize dissemination of relevant Kentucky criminal-history information to the Cabinet for Health and Family Services, Office of Inspector General, for determining eligibility for employment, licensing, volunteer service, or contractor/vendor work, and authorize the Office of Inspector General to release any State criminal-history record to the qualified entity as permitted by law. I understand I may be hired provisionally while the check is processed and may be denied unsupervised access to children, elderly persons, or individuals with disabilities. I understand I may request a copy of my criminal-history report, challenge its accuracy and completeness before a final decision, and that the Cabinet, Kentucky State Police, and their personnel are released from liability for good-faith actions taken to comply with 906 KAR 1:190.

Fingerprint and Provisional Employment Requirements

Provider/Facility Name: Good 2 B Home Adult Day Healthcare, LLC

For this type of employment or licensure, State and Federal law require a State and national criminal background check as a condition of employment. I understand that: (1) fingerprints are required; (2) I must complete and sign the Waiver Agreement and Statement and provide government-issued photo identification; (3) the background check includes required abuse registries, applicable licensing-board validation, and fingerprint-supported Kentucky and FBI criminal-history checks; (4) KSP and the FBI may retain fingerprint images and associated information and process future searches, including latent-fingerprint searches, and may notify the Cabinet of subsequent arrests or convictions; (5) an employer may hire provisionally while the check is processed; (6) my Social Security Number is requested to keep records accurate; (7) information provided to KY-NBCP will be kept confidential as required by law; and (8) I have the right to request and inspect my criminal-history record and request correction of inaccurate information. I have read and understand these disclosures.