Criminal Offender Record Information (Cori) Acknowledgement Form (Page 2 of 2) in pdf

Criminal Offender Record Information (Cori) Acknowledgement Form Page 2

The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

Division of Health Care Facility Licensure and Certification

99 Chauncy Street, 11th floor, Boston, MA 02111

617-753-8000

CORI

The Department of Public Health (Department) is required to conduct suitability reviews for all applicants applying

for licensure as new health care providers.

The review includes a criminal background check of the applicant.

Accordingly, The Department has been certified by the Executive Office of Public Safety, Criminal History Systems

Board, for access to reports from the criminal offender record information system.

The enclosed Criminal Offender Record Information (CORI) form must be completed and returned with the license

application for all individuals (use full names) identified below so that determinations of suitability and responsibility

can be made in a timely manner.

• All individuals who hold a 5% or greater ownership or managerial interest in the facility;

• If the applicant is a partnership, CORI forms must be completed for all general and limited partners with 5% or

greater ownership interest in the partnership;

• If the applicant is a for profit corporation, CORI forms must be completed for all officers, directors and holders of

5% or more of the corporation’s stock;

• If the applicant is a not for profit organization, CORI forms must be completed for the officers of the board of

directors, the executive committee, or other such governing body that has direct and ultimate control over the

operation and compliance performance of the facility.

• The program administrator.

In order to verify the information on your CORI request form, you may either (1) deliver your application to us in

person, at which time we will verify the information on your request form, or (2) include a photocopy of a

government-issued photographic identification with your request form.

Government-issued photographic identification includes, but is not limited to: state issued drivers license, state issued

photographic identification card, passport, or US military ID. We are not able to accept an identification card issued

by a private employer or, with the exception of a passport, by a non-US or state government agency.

If you have any questions or concerns regarding the completion of these CORI forms please contact Pearlina Mills

(617) 753-8124.

DPHCQ CORI Form May 2012

Criminal Offender Record Information (Cori) Acknowledgement Form Page 2