Health Care Worker Background Check Form

First Name *

Full Middle Name

Last Name *

Mailing Address

Physical Address if different

Other Names Used

Telephone

States Where you have lived?

Sex

Male

Female

Date of Birth

Height

Eye Color

Social Security Number (SSN)

Race

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.)

Have you ever had an administrative finding of Abuse, Neglect, or Theft?

Yes

No

If "Yes", give full details and state

Have you ever been convicted of a criminal offense other thatn a minor traffic violation (don not include convictions that have been expunged, sealted or a adjudicated delinquent)?)

Yes

No

If "Yes", give full details of each offense and the state in which convicted.

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.