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Iowa Department of Public Safety

Division of Criminal Investigation

Waiver Agreement and Statement

For National Criminal History Record Checks

as authorized by state legislation or federal statute

Pursuant to the Iowa User Agreement, this form must be completed and signed by every current or prospective licensee,

employee, volunteer, and contractor/vendor, for whom criminal history records are requested by a Qualified Entity (QE)

under state legislation or federal statute.

I hereby authorize

(Name of QE)

to submit a set of my fingerprints to the Iowa Department of Public Safety (DPS), Division of Criminal Investigation (DCI)

for the purpose of accessing and reviewing Iowa and FBI national criminal history records that may pertain to me. By

signing this Waiver Agreement, it is my intent to authorize the dissemination of any Iowa and/or national criminal history

record that may pertain to me to the QE with which I am or am seeking to be licensed, employed or to serve as a

volunteer. Furthermore, I authorize the QE to forward this agreement to DCI upon request.

I understand that, until the criminal history record check is complete, the QE may choose to deny me unsupervised

access to children, elderly or individuals with disabilities. I further understand that, if applicable, the QE may choose to

deny my application or grant me a limited or restricted license until the criminal history record check is complete.

I understand that I am entitled to challenge the accuracy and completeness of any information contained in the criminal

history report, if any, received on me. I understand that the procedures for obtaining a change, correction, or updating of

my criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34. I may obtain a

prompt determination as to the validity of my challenge before a final decision is made about my status as a licensee,

employee, volunteer, contractor or subcontractor.

☐

I have been convicted of a crime

I have not been convicted of a crime.

If convicted, describe the crime(s) and the particulars of the conviction(s) in the space below. Use additional paper as

needed:

☐

I am a current or prospective (check one):

Licensee

Employee

Volunteer

Contractor/Vendor

Please complete the following information as it appears on valid photo identification:

Printed Name:

Address:

Date of Birth:

Signature:

Date:

TO BE COMPLETED BY THE QUALIFIED ENTITY:

QE Name:

OCA:

Address:

Telephone:

Fax:

This waiver must be retained at the QE for one year after the applicant is no longer relevant to the QE or

one year post audit by DCI, whichever is longer. Do not send to DCI unless requested.

DCI-45 (07/15/15)

Form Dci-45 - Waiver Agreement And Statement - Iowa Division Of Criminal Investigation

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