Criminal History Check Procedure Verification Form printable pdf download

Serve Wisconsin

Criminal History Check Procedure Verification Form

____________________________________________________

Print Name of Member or Employee

Check one box:

AmeriCorps Member

Grant-funded Employee

Member/Employee will have recurring access to vulnerable populations (children age 17 or younger,

individuals age 60 or older, and/or individuals with disabilities) (see Item 8 below):

Yes

1. Verified the individual’s identity by examining her/his government-issued photo identification

card, such as a driver’s license.

2. Obtained prior, written authorization from the individual for the state criminal registry check,

FBI fingerprint check, if applicable, and the appropriate sharing of the results of such checks

within the program (not necessary for the NSOPR or WCCA checks).

3. Documented the individual’s understanding that selection for the position is contingent upon

the organization’s review of the individual’s criminal history, if any.

4. Ensured that screening practices comply with federal civil rights laws, including Titles VI and

VII of the Civil Rights Act of 1964 (and the CNCS implementing regulations under Title VI).

5. Conducted the state criminal registry check for Wisconsin and for the other state that the

individual resided in at the time of application, if applicable, for this individual. At minimum,

must be initiated before: (1) AmeriCorps member is enrolled and serves hours or (2)

before grant-funded employee begins working.

Date Wisconsin check completed, printed & considered: ______________

Date other state check is completed, printed & considered: ______________

Not applicable

6. Conducted the National Sex Offender Public Registry (NSOPR) check for this individual and

confirmed that all jurisdictions’ registries were available at the time of this check. Must be

completed before AmeriCorps member is enrolled and serves hours or before grant-

funded employee begins working.

Date check completed, printed & considered: ______________

7. Conducted the Wisconsin Circuit Court Access (WCCA) check for this individual. Must be

completed before enrolling AmeriCorps member.

Date check completed, printed & considered: ______________

WCCA check not applicable because this individual will be a Grant-funded Employee.

8. Conducted the FBI fingerprint check for this individual who will have recurring access to

vulnerable populations (children age 17 or younger, individuals age 60 or older, and/or individuals

with disabilities). At minimum, must be initiated before: (1) AmeriCorps member is enrolled

and serves hours or (2) before grant-funded employee begins working.

Date check completed, printed & considered: ______________

FBI fingerprint check not applicable because this individual will not have recurring

access to vulnerable populations.

Serve Wisconsin Criminal History Check Procedure Verification Form

Revised 07/24/2014

Criminal History Check Procedure Verification Form