Criminal History Check Procedure Verification Form (Page 2 of 2) in pdf

9. Verified that the criminal history checks do not report that the individual is registered or

required to be registered on a state sex offender registry, and do not report that the individual has

been convicted of murder.

10. Maintain the results of these checks in a separate and secure file.

11. Provided a reasonable opportunity for the individual to review and challenge the factual

accuracy of a result before action is taken to exclude the individual from the position.

Opportunity to review not applicable; individual not excluded from the position.

12. Provided safeguards to ensure confidentiality of any information relating to the criminal

history check, consistent with authorization provided by the applicant.

13. Considered the results of these checks in selecting the individual for service or employment.

14. Ensured that an individual, for whom the results of a required state criminal registry check

and FBI fingerprint check are pending, is not permitted to have access to children age 17 or

younger, individuals age 60 or older, or individuals with disabilities without being in the physical

presence of (check the applicable box(es) below):

An authorized grantee representative who has previously been cleared for such access.

A family member or legal guardian of the vulnerable individual.

An individual authorized, because of his or her profession, to have recurring access to the

vulnerable individual, such as an education or medical professional.

For checks that were pending, specify date of initiation and type of check (FBI, WI State, Other

[Specify] State): ______________________________________________________________

Item 14 is not applicable because this individual will not have recurring access to vulnerable

populations.

Item 14 is not applicable because results of the required state criminal registry check and/or FBI

fingerprint check were reviewed and considered prior to the individual starting service (AmeriCorps

Member) or beginning work (Grant-funded Employee).

The undersigned certifies that the items checked above have been completed and complied with in

accordance with all related federal and state regulations and procedures.

_______________________________________________________________

Signature and Date

________________________________________________________________

Printed Name and Title of Authorized Program Staff Representative

Serve Wisconsin Criminal History Check Procedure Verification Form

Revised 07/24/2014

Criminal History Check Procedure Verification Form Page 2