Background Check Form Hr
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3Rev. 03 April 2013
UT Health Northeast
CRIMINAL BACKGROUND CHECK FORM
Human Resources
Disclosures: In processing your application for employment, or at any time during your employment period, UT Health Northeast may obtain criminal records
and/or a consumer report or investigative consumer report for employment purposes, as authorized by state law and/or the Fair Credit Reporting Act (FCRA).
The report may include information as to my criminal record history. Should an investigative consumer report be requested, you will have the right to obtain
a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit
Reporting Act.
With few exceptions, you are entitled on your request to be informed about the information UT Health Northeast collects about you. Under Sections 552.021
and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code,
you are entitled to have UT Health Northeast correct information about you that is held by us and is incorrect, in accordance with the procedures set forth in
UTS139. You may be required to correct/contest criminal background records with the source of the record. The information that UT Health Northeast collects
will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different
types of information are kept for different periods of time. Disclosure of your Social Security Number ("SSN") is required of you in order for UT Health
Northeast to conduct a criminal background investigation, as mandated by Texas Government Code, Sections 411.094 and 411.086. Further disclosure of
your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable law.
THIS SECTION TO BE COMPLETED BY AN APPLICANT OR EMPLOYEE FROM WHOM A CRIMINAL BACKGROUND CHECK IS
REQUIRED
See Institutional HOP on Criminal Background Checks Policy 06.04.05
IMPORTANT: Print legibly using BLACK ink only. Fill out all information requested. If not applicable, enter N/A. Falsification of any information on this form will
void your application for employment and any actions based on it. The information on the application for employment, including any attachments, is property of
UT Health Northeast Administration.
Name:
Last
First
Full Middle Name
Maiden
List any former names used:
Social Security #:
Driver's License - State and #:
Ethnicity:
Black (not Hispanic) ____
Asian/Pacific Islander ____
Hispanic ____
White (not Hispanic) ____
American Indian/Alaskan Native ____
Gender:
Male ____
Female ____
Date of Birth (MM/DD/YY):
Height: ______________
List ALL residency information since the age of 17 – dates of residency, city, and state, beginning with your most current. Please
account for out of the country residency as well. If additional space is needed, please attach a separate sheet.
From (MM/YY)
To (MM/YY)
City
State
County/Country
No ____ Yes ____
1. Do you have any criminal convictions since age 17?
No____ Yes____
2. Do you have any deferred adjudications where the final disposition is still pending
(i.e. the original charge has not been dismissed)?
If Yes to either, list year(s) of conviction(s) and nature of offense(s) and penalty(ies). If additional space is needed, attach a
separate sheet.
Please provide court documentation related to convictions or deferred adjudication.
Year
Nature of Offense
Penalty
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