* = Required Information
Male Female
A chinese, Japanes, Filipino, Korean, Polynesisan, Indian, Indonesia, Asina Indian, Samoan, or any other Pacific Islander.
B Black or African American (Not Hispanic or Latino).
H Hispanic or Latino (Mexican, Puerto Rica, Cuban, Central or South American, or other Spanish culture or origin).
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.)
Yes No
Yes No
I certify that the above is true and correct and gibe my consent for my name to appear on IDPH's Health Care Worker Registry as a result of this criminal history records check.
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