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A1-GA Careers
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Application Type
Owner (Facility)
Applicant for Employment/Direct Access Employee (Facility)
Non-Employee (Facility Volunteer)
Contractor/Direct Access (Facility)
First Name
*
Middle Name
*
Last Name
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Phone Number
*
Format: (000) 000-0000.
Name of Facility
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I hereby authorize the Georgia Department of Community Health (DCH), Office of Inspector General, to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I understand a State and Federal fingerprint criminal background check will be conducted. By signing below, I am indicating that I have read and understand the terms and conditions of the attached Non-Criminal Justice Applicant's Privacy Rights and Policy Act Statements
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Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
SECTION II - CAREGIVER PORTAL - TO BE COMPLETED ONLY BY AN APPLICANT OR EMPLOYEE BEING FINGERPRINTED AS PART OF FACILITY LICENSURE. DOES NOT INCLUDE OWNERS OR FAMILY EMPLOYERS
APPLICANT TYPE
Applicant for Employment/Direct Access Employee (Facility)
Non-Employee (Facility Volunteer)
Contractor/Direct Access (Facility)
The Georgia Caregiver Portal only contains the eligibility status of applicants and employees who have successfully passed the background screening process. The Caregiver Portal does not contain the names of applicants and employees who are ineligible. Family employers can access the CCaregiver Portal to view a prospective applicant or current employee's eligibility to determine their suitability for employment to provide personal care services to that employer's elderly family member or wards. All services are performed at locations not licensed by DCH. Individuals should check one of the boxes below.
I agree to the results of my background check determination being available to family employers in the Georgia Caregiver Portal.
I am seeking employment only by licensed healthcare employers. I do not want or agree to the results of my background check determination being available to family employers.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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