Registry And Criminal History Record Check Consent And Release Form printable pdf download

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.

With

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through an authorized collection site or your application shall be deemed withdrawn and your will be required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

Registry And Criminal History Record Check Consent And Release Form

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