Nursing Home Resident Applicant Fingerprint Consent Form (Non-Pilot Submission) - Illinois State Police

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Nursing Home Resident Applicant Fingerprint Consent Form
(Non-Pilot Submission)
Pursuant to Public Act 096-1372, nursing home facilities are required to arrange for the fingerprinting of
residents they determine to be identified offenders. This form is to be completed by facilities seeking to have a
Fee Applicant fingerprint based criminal history record check completed in accordance with the Act. This form
is designed to capture the necessary information required by live scan vendors to ensure the fingerprints are
submitted properly. The live scan vendor will use the applicant information contained on the form to help
confirm the identification documentation provided by the applicant before the fingerprints are taken. This
document also serves as a consent form. Consequently, the form must be signed by the applicant in order to
authorize the release of any criminal history record information that may exist regarding the applicant. Once
the form is completed and signed, the original copy is to be retained in the files of the nursing home facility.
One copy is to be provided to the live scan fingerprinting vendor and one copy is to be given to the applicant.
The applicant is required to undergo an Illinois State Police and Federal Bureau of Investigation (national)
fingerprint based criminal history record information inquiry if the nursing home has deemed the applicant
to be an identified offender. The results of both inquires will be forwarded to the Illinois State Police, Division
of Internal Investigation by the Bureau of Identification.
Facility Information
Facility Name:
Facility ID:
Contact Person Name:
Contact E-mail and Phone #:
Applicant Information
Sex:
Race:
Date of Birth:
Name:
Height:
Weight:
Eye Color:
Hair Color:
Place of Birth:
SSN (optional):
Livescan Vendor/Appointment Information
Live Scan Fingerprint Vendor Name:
Address:
Phone Number:
Appointment Date:
Appointment Time:
Requesting Agency ORI Identifier:
Purpose Code:
Request Type:
X
IL920701Z (ISP/DII)
RNP (Resident Non-Pilot)
State and FBI
Privacy Statement
I, the undersigned, hereby authorize the release of any criminal history record information that may exist
regarding me from any agency, organization, institution, or entity having such information on file. I am aware
and understand that my fingerprints may be retained and will be used to check the criminal history record
information files of the Illinois State Police and/or the Federal Bureau of Investigation, to include but not limited
to civil, criminal and latent fingerprint databases. I also understand that if my photo was taken, my photo may be
shared only for employment or licensing purposes. I further understand that I have the right to challenge any
information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete
pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 20 ILCS 2630/7 of the Criminal Identification
Act. For instructions please visit:
Applicant Consent
Applicant Name (printed):
Date:
Applicant Name (signature):
Date:
Revised 8/2015

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