HR Credentialing Questionnaire

HR Credentialing Questionnaire

Personal Information

Address:

Phone:    Email:

Date of Birth:    Social Security Number:

Position & Credentialing Details

Reporting Manager:    Proposed Start Date:

Full-time    Part-time    Per Diem / PRN    Contract

Professional Licenses & Certifications

Issuing State/Authority:    License Number:    Expiration Date:

Employment History (Most Recent First)

Job Title:    From:    To:

Job Title:    From:    To:

Education

Major / Program:    Graduation Date:

Professional References

Relationship:    Phone:    Email:

Relationship:    Phone:    Email:

Relationship:    Phone:    Email:

Background & Disclosures

Have you ever had a professional license or clinical privileges denied, suspended, revoked, restricted, or subject to disciplinary action? Check if yes. If yes, provide details below.

Have you ever been involved in a malpractice claim or settlement? Check if yes. If yes, provide details below.

Have you ever been convicted of a felony or misdemeanor related to professional practice, patient care, or financial misconduct? Check if yes. If yes, provide details below.

Are you legally authorized to work in the United States? Check if yes.

Do you consent to pre-employment and periodic drug screening, background checks, and verification of credentials and references as required by the organization? Check to consent.

Authorizations, Release & Certifications

I certify that all information provided in this HR Credentialing Questionnaire is true, complete and correct to the best of my knowledge. I understand that any omission, misrepresentation or falsification of information may result in denial of credentialing, withdrawal of an offer of employment, or termination of employment.

I authorize the organization, its agents and representatives to verify the information provided, to contact employers, educational institutions, licensing boards, professional references and other third parties, and to obtain background and consumer reports necessary for credentialing and employment decisions. I hereby release from liability any person, institution or organization providing information in good faith pursuant to this authorization.

I understand that information provided on this form will be used for credentialing, background screening, compliance and related employment decisions, and may be maintained in personnel and credentialing records consistent with applicable law and organizational policy.

Emergency Contact

Relationship:    Phone:

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