UF Health Shands Hospital Disclosure and Authorization

Disclosure and Authorization for University of Florida Academic Health Center/Shands Hospital
This authorization is required for us to complete your background check for University of Florida Academic Health Center/Shands Hospital. The information you provide in this form is confidential and secure.

By completing the authorization online, you hereby certify that your electronic signature may be used as if it were your original handwritten signature by iReviewNow, SecurTest, Inc., and/or court researchers, investigators, or government entities to verify your authorization for your background check. You hereby give consent for SecurTest, Inc. to periodically re-check your background report without further notice or consent.

You may complete this authorization online by pressing "Next." The authorization will not be complete until you click the "Submit" button on the final page. You must complete this authorization in one sitting. YOUR INFORMATION IS SSL ENCRYPTED AND SECURE!

An alternative version of this form, which can be completed offline or by hand may be available by contacting SecurTest, Inc. at 1(800) 445-8001 or compliance@securtest.com.
You must answer each question and press "Next." The website and form are confidential and secure. You can be confident that your personal identifiers are protected and encrypted.

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

The CLIENT identified herein may obtain information about you from a third-party consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by SecurTest, Inc., 600 Grand Panama Blvd., Suite 202, Panama City Beach, FL 32407; tel. # 800.445.8001; www.securtest.com. The scope of this disclosure is all encompassing, however, allowing the Client to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.
Today's Date

MonthDayYear
Signature

Clear

V. I understand that if I am a resident of California, Minnesota, Oklahoma, Connecticut, or New York, I may obtain a copy of the background report.*

I understand.
Please note, regardless of your state of residency, you will automatically have access to your report through iReviewNow.

You will be provided a separate authorization to sign if a credit report is being obtained by the CLIENT. Absent such notice, SecurTest WILL NOT check your credit.

Please Carefully Complete the Following
Your Legal First Name*
Your Legal Last Name*
Your Legal Middle Name (if any)

The following information will be used to identify you as the subject of your individual background report once it has been ordered. You will be prompted for additional identifiers while ordering your report after completing this form.
Your Birth Date*

MonthDayYear
Please type your social security number or Work Authorization number if not issued an SSN card*
A scanned or photo image of your ID may expedite your background check. You may upload a scanned copy or a cell phone photo of your Government issued ID.
Upload a clear copy of your ID

Upload a File

Cancelof

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Email Address is REQUIRED*
Please email me a copy of my report.

NoYes, only if there is a criminal record being reportedYes
Your Cell Phone Number. We may need to call you to expedite your background check.*

Area CodePhone Number
Your Home Phone Number. While this field is optional, we may need to call you to expedite your background check.

Area CodePhone Number

I am a California Resident*

YesNo

California Notice

The Employer listed herein (“EMPLOYER”) may obtain from SecurTest, Inc.(“SecurTest”), 600 Grand Panama Blvd., Suite 202, Panama City Beach, FL 32407 (800) 445-8001 www.securtest.com,a consumer report and/or an investigative consumer report (“REPORT”) that contains background information about you in connection with your employment or employment application for employment purposes. If you are hired, to the extent permitted by law, EMPLOYER may obtain from SecurTest further REPORTS throughout your employment for an employment purpose without providing further disclosure or obtaining additional consent.
The REPORT may contain information about your character, general reputation, personal characteristics and mode of living. The REPORT may include, but is not limited to, credit reports and credit history information; criminal and other public records and history; public court records (e.g., bankruptcies, tax liens and judgments); motor vehicle and driving records; educational and employment history, including professional disciplinary actions; drug/alcohol test results; and Social Security verification and address history, subject to any limitations imposed by applicable federal and state law. This information may be obtained from public record and private sources, including credit bureaus, government agencies and judicial records, former employers and educational institutions, and other sources.
If an investigative consumer REPORT is obtained, in addition to the description above, the nature and scope of any such REPORT will be employment verifications and references, or personal references.
You may inspect SecurTest’s files concerning you during normal business hours and upon reasonable notice. You can inspect the files at SecurTest’s offices if you furnish proper identification, and you can obtain a copy by paying duplication costs. One other person can accompany you if he or she furnishes reasonable identification. You can also obtain a copy of your files by sending SecurTest at the address listed above a written request, including proper identification, by certified mail. SecurTest will give you a summary of the information in the files by telephone if you submit a written request including proper identification. SecurTest has trained personnel who can explain the information furnished to you, and can provide a written explanation of any coded information contained in your files. “Proper identification” includes documents such as a valid driver’s license, Social Security card, military identification card or credit card. If necessary, SecurTest may request additional information about your employment and personal or family history to verify your identity.
I request to receive a copy of my report

Send me a copy.
Signature*

Clear

I am a New York Resident*

YesNo

New York Notice

In connection with my application for employment (including contract for services) with University of Florida Academic Health Center/Shands Hospital.

I understand that consumer reports which may contain public record information and investigative consumer reports consisting of interviews with employers, neighbors, friends, and associates may be requested from SecurTest, Inc., a consumer reporting agency. These reports may include the following types of information: names of employers and dates of previous employment, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records. I hereby consent to your obtaining the above information from such agency.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to SecurTest, Inc upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which the agency has previously furnished within the two year period preceding my request.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports and investigative consumer reports at any time during my employment (or contract) period.

I acknowledge receipt of a copy of Article 23-A of New York Correction Law.

New York State Labor Law §201-f provides that every employer shall post, in a place accessible to his or her employees, a copy of Correction Law Article 23-A relating to the licensure and employment of persons previously convicted of one or more criminal offenses.
Signature - Use Your Mouse to Sign in the Box*

Clear
Signature /s/*
Type your full legal name as your electronic signature.

I have lived or worked in the State of Georgia?*

YesNo

Georgia Name-Based Criminal History Record Information (CHRI) Consent/Inquiry Form
Full Name*

First NameMiddle NameLast NameSuffix
Maiden or Alias Name

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
Social Security Number*
Georgia requests your Race and Sex (Gender) to perform a more accurate and complete Criminal History Search. Your answers will not be used in the employment process or be shared with the employer or other parties by SecurTest.
Race*
Sex/Gender*
I hereby authorize SecurTest, Inc. and PSI Background Screening to conduct an inquiry for the purpose of Employment and receive any Georgia and/or national CHRI as authorized by state and federal law.

This authorization is valid for 90 days from date of my signature.

I do not give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment.

Purpose Code Used (check one): Note: Only one inquiry may be performed per consent form.

NON-CRIMINAL JUSTICE PURPOSES
E = Employment
Georgia Signature*

Clear
Use your Mouset to Sign

I hereby authorize SecurTest, Inc. to transmit a copy of my background report to me in a secure electronic manner. I understand that receiving a copy of my report, use of iReviewNow, or providing responses or disputes using iReviewNow is a free service, which allows me instant access and other valuable benefits described in the Terms and Conditions found at iReviewNow.com and below.*

I agree to the SecurTest, Inc. terms and conditions.
HOW TO CONTACT SECURTEST, INC.

SecurTest, Inc. ★ 600 Grand Panama Blvd. Ste 202, Panama City Beach, FL 32407

★ (800) 445-8001 (toll-free to speak to SecurTest) ★ Fax (866) 580-4851 ★ compliance@securtest.com ★ or by going to www.securtest.com
All of the notices required by law are found at SecurTestNotices.pdf. A copy of these notices are attached to the email transmitted to you when you click Submit.
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Disclosure and Authorization for University of Florida Academic Health Center/Shands Hospital

Please Carefully Complete the Following

Georgia Name-Based Criminal History Record Information (CHRI) Consent/Inquiry Form