Form Ssa-89 - Background Information Sheet - Uconn Health

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BACKGROUND INFORMATION SHEET

PLEASE COMPLETE ALL SECTIONS AND SIGN AT THE BOTTOM

The following information is being solicited for purposes of conducting pre-employment criminal and/or other

background checks only and is not used in employment decisions unrelated to the results of the background check.

Name: ________________________________________________________

Home Address: ________________________________________________

Last First Middle (spell out)

Number Street City/Town State Zip

Social Security Number: __________________________________________

Date of Birth: __________________________________________________

Contact Phone: ___________________ Home Phone: __________________

MM/DD/YYYY

Place of Birth: _________________________________________________

e-mail: ________________________________________________________

City and State or Country

___

Marital Status:

Single

Married

Divorced

Citizenship: ________________________ Visa Status: _________________

Maiden Name: _______________________________________________________

__________________________________________________

Aliases:

Drivers License ___ Yes ___ No

______ Race

______ Eyes

______ Height

Physically Disabled:

State: ___________ License #: ____________________________________

______ Sex

______ Hair

______ Weight

____ Yes _____ No

List the states that you have lived in the last 7 years:

Identifying Scars/marks/tattoos (type & location):

_____________________________________________________________

Are you related to, or an unmarried partner of, an employee at UConn Health?

___YES

___NO

If “YES” list below. Continue on the reverse side if necessary. Per UConn Health Policy #2002-51 a relative is a spouse, father, mother, sister, brother, child, the spouse of a child, or any relative who is

domiciled in the employee’s household.

Name

Relationship

Department

Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently pending against you?

___YES

___NO

If “YES” list all cases below, providing details as indicated. Continue on the reverse side if necessary. Special Note: Under the provisions of (C.G.S. § 46a-80 a person is not disqu

solely because of a prior conviction of a crime. The state can deny employment if a person is found unsuitable after considering (1) the nature of the crime, (2) information relating to the degree of rehabilitation,

and (3) the time elapsed sine the conviction. You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General

Statutes §46b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records that may

that a child was a member of a family with service needs (C.G.S. § 46b-146), an adjudication as a youthful offender (C.G.S. § 54-76o), a criminal

charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon (C.G.S. § 54-142a).

Date

Place

Court Location

Offense(s)

Disposition

organizations? ___YES ___NO

Department of Correction will be submitted to the Connecticut State Police and the FBI for a criminal history check.

Date

Place

Agency

Funding

Current Status

Have there ever been any actions against your professional license(s)?

___YES

___NO

___N/A

If “YES” list all cases below, providing details as indicated. Continue on the reverse side if necessary.

Date

Place

Agency

Funding

Current Status

Have you brought or will you be bringing (or having transported) to UConn Health ANY biological materials that are pathogenic in humans,

animals or plants, including but not limited to viable organisms or genetic elements of pathogenic viruses, bacteria, biological toxins, fungi,

rickettsia, mycoplasma or parasitic organisms?

___YES

___NO

If “YES”, IMPORTANT NOTE: You must contact Research Safety 860/679-2723 or rwallace@uchc.edu before transporting any biological, chemical or radioactive materials to UConn Health.

I certify that the information provided by me in the Background Information sheet is COMPLETE and TRUE to the best of my knowledge and

is made in good faith. I understand that if I knowingly make any misstatement of facts or fail to provide required information I am subject to

disqualification or dismissal and other penalties as they may be prescribed by law, policy, or regulation. This sheet is not complete without

a wet signature. Digital signatures are not acceptable.

SIGNATURE: ___________________________________________________________________ DATE SIGNED: ____________________________________

OFFICIAL USE ONLY

MUST BE COMPLETED BY HIRING DEPARTMENT

PUBLIC SAFETY USE ONLY

Result/Date

submitted

___Abromaitis D ___Duggal J

___Hobson M ___Leone M