Registry And Criminal History Record Check Consent And Release Form


Registry and Criminal History Record Check
Consent and Release Form
This form is a provided as a courtesy for the use of employers. Other versions of this form may also be used
for the purposes of Title 63 O.S. § 1-1947(H), which requires that an applicant shall provide the employer a
government photo identification of the applicant and written consent for the employer to conduct a registry
screening and the Bureau [Okla. State Bureau of Investigation (OSBI)] to conduct a state and national criminal
history record check under this section. The employer shall maintain the written consent and information
regarding the individual’s identification in their files for audit purposes.
For the purposes of documenting the individual's identification, it is recommended a copy of the identification
be maintained with the applicant's written consent.
Employer must retain the signed applicant consent.
Instructions to Applicant:
Prior to employment with an employer subject to the Long Term Care Security Act [63
O.S. 1-1945 et. seq.], an applicant must consent to a check of state and/or national licensure, certification, abuse,
exclusion and offender registries, and fingerprinting for a state and national criminal history records check as
required. Applicants with an active employment history in OK-SCREEN or previously fingerprinted for a
license, certification or permit in Oklahoma where the authority having jurisdiction for the license,
certification, or permit employs electronic criminal history monitoring, may not require fingerprinting.
your written consent below, the employer will submit your information through the OK-SCREEN portal for
checks against state and national registries. If cleared, and the employer wishes to proceed, you will be notified
via email or telephone the employer has authorized you to schedule an appointment for fingerprinting. You will
be responsible for a Ten Dollar ($10) administrative processing fee at the time the appointment is scheduled
unless the employer elects to pay the fee. You will have ten (10) calendar days to submit your fingerprints
through an authorized collection site or your application shall be deemed withdrawn and your will be required
to start the application process over. [63 O.S. § 1-1947(I)(4)]
Declarations: By signing this form I consent to registry screening and submission of my fingerprints to the
Oklahoma State Bureau of Investigation (OSBI) for forwarding to the Federal Bureau of Investigation for the
purpose of conducting a state and national criminal history records check pursuant to 63 O.S. § 1-1947(H). I
understand that the results will be shared with the Oklahoma National Background Check Program (ONBCP)
operated by the Oklahoma State Department of Health (OSDH).
I understand that if my criminal history record check results reveal information that prevents the Department
from making a final determination of employment eligibility, I will be given notice and will have sixty (60) days to
make any necessary corrections or additions for the Department to review. If I am unable to make corrections or
additions to the record within the sixty (60) days, the Department shall deny eligibility based on the disqualifying
results and shall notify me of my right to appeal. The notice shall include the reasons I was found not eligible for
employment and a statement that I have a right to appeal the decision. [63 O.S. § 1-1947(K)]
I understand that should I be selected for employment, and as a condition of continued employment, I agree to
report to the employer immediately upon being arraigned, indicted, convicted, or pleading guilty or nolo
contendere to one or more of the criminal offenses applicable to my license, certification, permit or
employment class; or upon being the subject of a substantiated finding on a registry as described in this Consent
and Release and Title 63, Section 1-1947. I further understand that reporting of an arraignment under this
subsection may be cause for leave without pay, placement under direct supervision, restriction from direct
patient access, termination, or denial of employment. [63 O.S. § 1-1947(Q)]
Oklahoma National Background Check Program -
Continued on Page 2
Ver. 01/31/2014


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