Can this form be e-signed?

Yes, an Employee CHI Form can be signed electronically when the electronic signature meets ESIGN/UETA requirements. Ensure intent, consent, signer attribution, and retention; consumer-facing records may require ESIGN consumer disclosure per 15 U.S.C. §7001(c).

Is HIPAA compliance required?

If the form collects protected health information and the employer is a HIPAA-covered entity or business associate, handle records under HIPAA rules. Use a BAA where required and retain records per 45 CFR §164.530(j).

Do I need a notary or witness?

Most Employee CHI Forms do not require notarization, but state-specific rules may require witnesses or notary for certain declarations. Verify with state law; for legal documents like power of attorney or affidavits, follow state witness/notary requirements.

How long must I retain the form?

Retention depends on purpose: employment and payroll records follow federal minima, while healthcare-related CHI triggers HIPAA timelines. See federal retention standards and company policy; consult legal counsel for overlapping regulatory obligations.

What if the employee refuses to sign?

If an employee declines to provide CHI, document the refusal and explain consequences for benefits or accommodations. For mandatory health screenings tied to safety or OSHA, employers should follow legal guidance before taking adverse actions.

Can third parties submit medical records?

Yes if authorized. Attach a signed release or provider authorization specifying what may be disclosed and to whom. Limit disclosures to the minimum necessary and retain authorization alongside the CHI Form for auditability.

Electronic Signature
Templates
HR
Employee CHI Form

Employee CHI Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Employee CHI Form

Purpose: This Employee CHI Form (Criminal History Inquiry and personnel information) collects personnel data, employment history, education and references, and obtains the employee's authorization to conduct background checks and contact prior employers. Information provided will be used for pre-employment screening and personnel recordkeeping. Providing false or misleading information may constitute grounds for denial of employment or termination.

Personal Information

Full Legal Name Other Names Used (maiden, aliases) Date of Birth Social Security Number Current Address Phone Number Email Address

Position Information

Position Title Department Reporting Manager Proposed Start Date Compensation (Annual or Hourly) Employment Type (select all that apply)

Full-time Part-time Temporary Contract

Work Location

Employment History

Employer 1

Company Name Company Address Supervisor Name & Phone Job Title Dates Employed Primary Responsibilities Reason for Leaving

Employer 2

Company Name Company Address Supervisor Name & Phone Job Title Dates Employed Primary Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Graduation or Completion Date Additional Training / Licenses

References (Professional)

Reference 1 — Name Phone Email Relationship Reference 2 — Name Phone Email Relationship Reference 3 — Name Phone Email Relationship

Criminal History Inquiry

The following questions relate to criminal history. A conviction or pending charge will not necessarily disqualify you from employment; each matter will be reviewed with respect to relevance to the position applied for. You must answer truthfully. Failure to disclose required information may result in withdrawal of an offer or termination.

Have you ever been convicted of a felony?

Yes No

Have you ever been convicted of a misdemeanor involving theft, dishonesty, violence, or a controlled substance?

Yes No

Are there any criminal charges currently pending against you?

Yes No

If you answered Yes to any question above, provide full details including jurisdiction, date, charge, disposition, and sentence.

Authorizations and Legal Disclosures

Authorization to Obtain Records: I authorize the Company and its agents to obtain and review criminal records, consumer and investigative consumer reports, driving records, and other background information about me for purposes of evaluating my application for employment and for employment-related decisions as permitted by law. I understand that the Company will use this information only in compliance with applicable law.

I hereby authorize the Company to obtain background information and contact prior employers and references.

I authorize I do not authorize

Release and Liability Waiver: To the extent permitted by law, I release all persons, agencies and entities from any liability arising from the release of information related to my background, criminal record, employment history, education, and references. I agree the Company is not liable for actions taken based on information obtained in the background check process.

At-Will and Equal Opportunity Statements

At-Will Employment: If employed, I understand that my employment with the Company is at-will, which means that either the Company or I may terminate the employment relationship at any time, with or without cause or notice, unless a separate written agreement signed by an authorized Company representative states otherwise.

Equal Opportunity: The Company provides equal employment opportunity to all qualified applicants and employees without regard to race, color, religion, sex, pregnancy, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law. Reasonable accommodations will be provided as required by law.

Applicant Certification and Consent

I certify under penalty of perjury that the information provided on this form is true, correct and complete to the best of my knowledge. I understand that misrepresentation, omission or falsification of information may be grounds for refusal of employment or immediate dismissal if discovered after hire. I consent to the release of the information provided in this form and to any background checks described above.

Additional Applicant Statement (optional)

Print Name:

Signature:

Date:

What the Employee CHI Form Is and When It’s Used

Employee CHI Form is a standardized internal HR document used to collect Confidential Health Information (CHI) from employees for workplace health programs, accommodations, or benefits administration. The form records employee identifiers, specific health conditions or restrictions, authorizations to share information with designated staff, and any accommodation requests. It supports compliance with privacy rules when handled securely and establishes consent and attribution for any disclosures. Employers commonly use the form to document medical leaves, return-to-work clearances, and reasonable accommodation processes while maintaining a clear audit trail and controlled access.

Why a Standard Employee CHI Form Matters

Using an Employee CHI Form centralizes sensitive health disclosures, documents employee consent, and clarifies accommodation needs. Properly completed forms reduce administrative ambiguity, support regulatory compliance obligations such as HIPAA, and create a verifiable record for personnel decisions and benefit administration.

Who Completes and Uses the Employee CHI Form

Common users include HR professionals, occupational health staff, managers with accommodation responsibilities, and legal or benefits administrators.

Human resources staff who intake forms, maintain records, and coordinate accommodations.
Occupational health clinicians documenting restrictions, return-to-work notes, and medical clearances.
Supervisors and managers needing documented accommodation details for scheduling and job modifications.

Employees complete designated sections and sign to authorize disclosures; third parties (e.g., providers) may complete release fields when applicable.

Step-by-Step: Collecting and Processing an Employee CHI Form

Follow these steps to collect and process Employee CHI Forms consistently while preserving confidentiality and legal compliance.

01

Prepare Form: Use the current Employee CHI Form template and employer letterhead.
02

Explain Purpose: Tell employee why information is needed and how it will be used.
03

Collect Consent: Obtain signature and date; include permission to share limited information.
04

Secure Storage: Store completed forms in restricted files per HIPAA and company policy.

FAQs and Troubleshooting for Employee CHI Forms

Common questions about completing, submitting, and safeguarding Employee CHI Forms, with quick answers to practical issues encountered by HR and employees.

Need help? Contact support

Can this form be e-signed?
Yes, an Employee CHI Form can be signed electronically when the electronic signature meets ESIGN/UETA requirements. Ensure intent, consent, signer attribution, and retention; consumer-facing records may require ESIGN consumer disclosure per 15 U.S.C. §7001(c).
Is HIPAA compliance required?
If the form collects protected health information and the employer is a HIPAA-covered entity or business associate, handle records under HIPAA rules. Use a BAA where required and retain records per 45 CFR §164.530(j).
Do I need a notary or witness?
Most Employee CHI Forms do not require notarization, but state-specific rules may require witnesses or notary for certain declarations. Verify with state law; for legal documents like power of attorney or affidavits, follow state witness/notary requirements.
How long must I retain the form?
Retention depends on purpose: employment and payroll records follow federal minima, while healthcare-related CHI triggers HIPAA timelines. See federal retention standards and company policy; consult legal counsel for overlapping regulatory obligations.
What if the employee refuses to sign?
If an employee declines to provide CHI, document the refusal and explain consequences for benefits or accommodations. For mandatory health screenings tied to safety or OSHA, employers should follow legal guidance before taking adverse actions.
Can third parties submit medical records?
Yes if authorized. Attach a signed release or provider authorization specifying what may be disclosed and to whom. Limit disclosures to the minimum necessary and retain authorization alongside the CHI Form for auditability.

Security and Compliance Checklist for CHI Handling

Encryption: TLS 1.2/1.3 transit; AES-256 at rest

HIPAA: Requires BAA for protected health information

Audit Trail: Timestamped events, signer attribution, IP logs

Standards: SOC 2 Type II; ISO 27001 certified

Regulatory: ESIGN, UETA, 21 CFR Part 11 compliance

Access Controls: Role-based permissions and two-factor options

Key Risks and Potential Consequences of Errors

HIPAA Breach: Civil fines and corrective actions

Unauthorized Disclosure: Potential disciplinary action

Data Integrity: Incomplete forms impair compliance

Employment Decisions: Risk of discrimination claims

Missing Consent: Can invalidate disclosures

Recordkeeping Failures: Regulatory penalties possible

Common Preparation Mistakes to Avoid

Incomplete identity fields lead to mismatched records and delays in benefits or accommodation processing; always verify legal name and employee identifier.
Using vague descriptions for medical limitations forces follow-up requests and slows decisions; include functional limitations and expected duration.
Failing to secure signed releases prevents legitimate communication with healthcare providers and can block verification.
Storing forms with general personnel files without access controls increases exposure risk and may breach HIPAA obligations.

How CHI Forms Flow Through Your Organization

This flow shows routing from employee submission through review, accommodation determination, and secure storage with audit logging for compliance oversight.

Employee Submits: Employee completes form and signs consent.
HR Review: Assess request and request medical clarification if needed.
Decision: Determine accommodation, document action, and notify parties.
Archive: Store in secure records with restricted access.

Recommended Digital Workflow Settings for Employee CHI Forms

Configure digital workflows to capture CHI fields, collect signatures, route approvals, and log all events for audit and retention.

Field	Configuration
Signature Method	Email link; support for SMS code authentication.
Authentication	Email verification; optional two-factor for sensitive records.
Routing	Sequential approvals: HR then manager then legal if needed.
Retention Policy	Encrypted storage, access logs retained per HIPAA/IRS rules.

Platform Requirements for Secure eSubmission and Storage

Platform needs for digital CHI handling include secure file formats, integrations, and access controls to enforce privacy and retention.

File Formats: PDF, DOCX, and encrypted storage.
Integrations: HRIS, payroll, and EHR systems supported.
Authentication: SSO, SAML, and optional 2FA.

Timing Considerations and Deadlines for CHI Form Processing

Key timing considerations for Employee CHI Forms, including immediate handling, retention triggers, and deadlines for tax or benefits reporting.

Acknowledge Receipt Within One Day:

Acknowledge receipt to employee within one business day when sensitive data provided.

Provide Medical Documentation When Requested by HR:

Provide medical documentation within timeframe requested by HR or benefits team.

Aim To Complete Accommodation Decision Within Timeline:

Aim to resolve accommodation requests within interactive process timelines, typically 30 days.

Record Reportable Benefits Per Payroll and IRS Rules:

Ensure any reportable benefits recorded per payroll cycle and IRS rules.

Start Retention From Creation Or Termination Date:

Retention period starts at creation date or employment termination, whichever applies.

Key Processing Milestones From Submission to Archive

Major processing milestones for Employee CHI Forms from submission to archival, shown as sequential stages to guide administrators and monitor SLAs.

01

Form Submission

Employee submits form and any supporting documents electronically or on paper.

02

Intake Review

HR verifies completeness, identity, and consent before routing for clinical review.

03

Clinical Assessment

Occupational health or treating clinician provides functional assessment or clearance.

04

Disposition and Archive

Implement accommodation or administrative action; record decision and archive securely.

eSignature Vendor Comparison for Employee CHI Form Workflows

Pricing and feature comparison for eSignature vendors used when processing Employee CHI Forms, with signNow listed first per platform rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

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