Registry And Criminal History Record Check Consent And Release Form (Page 2 of 2) in pdf

Consent and Release Form (Continued)

Page 2

I understand the OSDH will store the records of an employer’s enrolled employees, the results of the screening

and criminal arrest records search, and an identifier issued by the OSBI for the purposes of receiving an

automatic notification from the OSBI if a subsequent criminal arrest record submitted into the system matches a

set of fingerprints previously submitted. Upon notification, the OSBI will immediately notify the Department and

the Department will immediately notify the employee. Information in the database established under this

subsection is confidential, is not subject to disclosure under the Oklahoma Open Records Act, and shall not be

disclosed to any person except for purposes of this act or for law enforcement purposes. The employee shall

promptly respond to Department inquiries regarding the status of an arraignment or indictment. Reporting of an

arraignment or indictment 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(S)]

Pursuant to 63 O.S. § 1-1947(I)(1), the employer shall submit the applicant's name, any aliases, address, former

states in which the applicant resided, social security number, and date of birth. Providing the requested

information is voluntary; however, failure to furnish the information may affect timely completion or approval

of your application. PLEASE PRINT CLEARLY:

This form requests this information for the purposes of a state and national criminal history records search.

These names must appear as recorded on your birth certificate or other official record.

First Name: ________________________________ Middle Name: __________________________________

Maiden Name (If Applicable): ___________________ Last Name: ____________________________________

What Other Aliases/Names Have You Used? ______________________________________________________

Date of Birth:

____________ Place of Birth: _____________________ Race/Ethnicity: ________________



Gender:

Male

Female Height: ______ Weight: _____ Hair Color: __________ Eye Color: __________

Telephone Number: __________________________ Social Security Number: __________________________

Present Address: ____________________________________________________________________________

Present City/State/Zip: _______________________________________________________________________

In What Other States Have You Lived After 18 Years Of Age? _________________________________________

___________________________________________________________________________________________

E-Mail Address: _____________________________________________________________________________

My signature acknowledges that I have read, understand and accept the terms and conditions outlined in this

form. I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the FBI for

conducting a state and national criminal history records check.

Applicant's Signature

Date

Oklahoma National Background Check Program -

Ver. 01/31/2014

Registry And Criminal History Record Check Consent And Release Form Page 2