Michigan Workforce Background Check Consent Form

Health Facility or Agency

Date:

Employment Applicant Name:

Facility Name:

The health facility/agency:

a. May not knowingly employ a worker, having direct access to patients or residents, who has been convicted of a relevant crime or has been the subject of a state or federal agency substantiated finding of patient or resident neglect, abuse, or misappropriation of property. “Direct access” means regular access to a patient or resident, or to a patient’s or resident’s property, financial information, medical records, treatment information, or any other identifying information.

b. May terminate the background check or may determine not to hire the individual at any stage of the process.

c. Must ensure that any background check information provided will only be used for the purpose of determining an individual’s suitability for employment in a long-term care setting.

d. Must retain verification of compliance with background check requirements.

e. Will make the final employment decision.

Part 1 – Consent to Conduct Background and Criminal Record Checks

As a condition of being considered for employment:

a. I hereby consent to and authorize the health facility/agency to conduct a background check that includes a search of state and federal abuse and neglect registries and databases, in addition to a fingerprint-based search of state and federal criminal history records. I understand that this consent extends to the release and sharing of such information with the Michigan Departments of Community Health, Human Services, Corrections, and State Police.

b. I hereby authorize the release of any relevant information to the health facility/agency to be used to conduct the background check as required under MCL 333.20173a and MCL 330.1134a.

c. I understand, except for a knowing or intentional release of false information, the health facility/agency has no liability in connection with a background check conducted under MCL 333.20173a and MCL 330.1134a, or the release of criminal history record information for the purposes of making an employment decision.

d. I understand that the health facility/agency will make the final employment determination. I also understand that the health facility/agency may terminate the background check or determine not to hire at any stage of the process.

e. I understand that the health facility/agency, in denying employment to an applicant, and reasonably relying on information obtained through a background check, is provided immunity from any action brought by an applicant due to the employment decision.

f. I agree to provide the information necessary to conduct a criminal background check.

Part 2 – This employment applicant information is required to process a complete and accurate criminal record check.

EMPLOYEE PERSONAL INFORMATION

First Name: Middle Name:

Last Name: Suffix:

OTHER NAME(S) USED (MAIDEN NAME, ALIAS)

First Name: Middle Name:

Last Name: Suffix:

Date of Birth: Country of Citizenship:

Place of Birth (City, State/Province):

Height: Weight: Hair Color: Eye Color:

Gender: Female Male

Race: Asian Black Hispanic Native American Pacific Islander White All

Social Security Number:

ADDRESS

Street Address:

City: State: Zip Code: County:

Phone Number:

Job Title: Conditional Hire Date:

RESIDENCY

Driver’s License or State/Canadian ID Number: State/Prov.

Has this employment applicant resided in Michigan continuously for the past 12 months? YES NO

PROFESSIONAL LICENSE(S) / CERTIFICATION(S)

1. License/Certification Number:

2. License/Certification Number:

3. License/Certification Number:

Part 3 – Employment Applicant Disclosure Statements

The following convictions and/or findings may disqualify you from working in long-term care facility/agency:

a. Relevant Crime Described under 42 USC 1320a-7 – 42 USC 1320a-7 is a statutory provision within the Federal Social Security Act which describes a number of crimes for which a conviction will exclude an individual from participation in any federal health care program. The crimes include patient abuse, health care fraud, as well as any crimes related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

b. Felony – Any felony, or an attempt or conspiracy to commit any felony.

c. Misdemeanor - Any state or federal crime that is substantially similar to the misdemeanors described below:

• Any misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use of force or violence.

• Any misdemeanor for assault if there was no use of a firearm or dangerous weapon and no intent to commit murder or inflict great bodily injury.

• Any misdemeanor involving criminal sexual conduct.

• Any misdemeanor involving abuse or neglect, torture, or cruelty.

• Any misdemeanor involving home invasion.

• Any misdemeanor involving embezzlement, larceny, fraud, theft or second or third degree retail fraud.

• Any misdemeanor involving negligent homicide.

• Any misdemeanor involving the possession, use or delivery of a controlled substance.

• Any misdemeanor involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance.

d. Any finding of Not Guilty by Reason of Insanity

e. Any substantiated finding of patient or resident neglect, abuse, or misappropriation of property

Listed below are all offenses that I have been convicted of, including all terms and conditions of sentencing, parole and probation, and/or any substantiated finding of patient or resident neglect, abuse, or misappropriation of property.

I certify that the above statements are correct and complete to the best of my knowledge.

Part 4 – Conditional Employment

If the health facility/agency determines it necessary to employ me pending the results of the state and federal criminal history background check, I understand the following:

a. If the background check does not confirm my disclosure statement made above, my employment will be terminated for good cause, unless and until I successfully prove that the disqualifying information is inaccurate, expunged or set aside.

b. If I knowingly provided false information regarding my identity, criminal convictions, or substantiated findings of patient or resident neglect, abuse, or misappropriation of property, I may be guilty of a misdemeanor punishable by imprisonment for not more than 93 days and/or a fine of not more than $500.00.

c. As required by MCL 333.20173a and MCL 330.1134a, I agree that as a condition of continued employment, I shall report in writing to the health facility/agency immediately upon being arraigned on a felony charge or convicted of one or more of the criminal offenses as described in MCL 333.20173a and MCL 330.1134a, or upon becoming the subject of an order or dispositional finding of “Not Guilty by Reason of Insanity”, or upon being the subject of a state or federal agency substantiated finding of patient or resident neglect, abuse, or misappropriation of property. Reporting of an arraignment is not cause for termination or denial of employment.

Part 5 – Applicant Rights

a. I understand that upon my request, the health facility/agency can provide a copy of any disqualifying record information found on any of the relevant registries or databases.

b. I understand that if I believe the results of any disqualifying information found on any relevant registry is inaccurate, it is my responsibility to contact the agency that maintains the registry to correct the registry information.

c. I understand that if I believe the results of the criminal history fingerprint record are inaccurate, or if the conviction contained in the criminal history record is one that may be expunged or set aside, I may file an appeal with the Department of Community Health.

Part 6 – Disclaimer

The State of Michigan is not responsible for any additional information, requirements, or use of any substitute forms that the above named health facility/agency provides to the applicant.