CNA Background Check

Complete this form in its entirety.
Pay the $30 fee at the Accounting counter in student services on the 2nd floor.
Take your paymentreceipt, copy of your social security card & this completed form to the Academic Division Office W102 to schedule your fingerprinting appointment.

Illinois Department of Public Health

Health Care Worker Registry, 525 W. Jefferson St., Springfield, IL 62761
Phone: (217) 785-5133

I hereby authorize the Illinois Department of Public Health (IDPH), IDPH's designee that train or test health care workers, staffing agency, or the health care employer to request a criminal history records check and I further authorize the Illinois State Police (ISP) to release information relative to the existence or non existence of any criminal record which it might have concerning me to the requestor solely to determine my suitability for employment or continued employment. I further authorize any agency which maintains records relating to me to provide same on request to the ISP or IDPH. I certify that the ISP and any agency, including IDPH, their employees or officers who furnish this information shall be held harmless from any and all liability which may be incurred as a result of releasing such information. I further acknowledge that a health care employer shall not be liable for the failure to hire or to retain an applicant or employee who has been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25)

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment or, if discovered after employment begins, could result in discipline up to and including my termination of employment.

I understand that the information requested below regarding sex, race, height, eye color, and date of birth is for the sole purpose of identification and the gathering of the above-mentioned information about me accurately, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my social security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

Name

First NameFull Middle NameLast Name

Nicknames

Maiden Name

Telephone

Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

States Where You Have Lived?

Sex

Height

Weight

Date of birth

MonthDayYear

Social Security Number

Race (choose from below)

Please use uppercase letters only. Accepted values: A, B, H, I, U, or W.

A	Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin)
B	Black or African American (Not Hispanic or Latino)
H	Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander.
I	American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.
U	Of undeterminable race. Of Untold mixture.
W	Caucasian (not Hispanic or Latino)

Original Hair Color

Eye Color

Place of Birth (State only)

Have you ever had an administrative finding of Abuse, Neglect, or Theft? If "Yes", give full details and state. Continue on back if more space is needed.

Full details of administrative finding of abuse, neglect, or theft and state:

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Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)? If "Yes", give full details of each offense and the state in which convicted. Continue on back if more space is needed.

Full details of each offense and the state in which convicted:

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Illinois Department of Public Health

Health Care Worker Background Check

Other Names Used

Steps to complete your Health Care Worker Background Check