Criminal History Record Check (Page 2 of 2) in pdf

DOH CHRC 101 (5/14) – Page 2

NYS Department of Health

AUTHORIZED PERSON

DESIGNATION FORM AND

CHRC Unit

NOTARIZED SWORN STATEMENT

Phone: 518-402-5549

Fax: 518-474-7477

PAGE 2

chrc@health.state.ny.us

CRIMINAL HISTORY RECORD CHECK

(CHRC)

For Department use only

PROGRAM

Leave blank

SECTION 3 - AUTHORIZED PERSON SWORN STATEMENT

By submitting a request for a criminal history record review through the DOH Criminal History Record Check (CHRC) Program on behalf of the

following Agency, I hereby attest to the following:

1. I am a duly Authorized Person, as defined in Section 845-b of the Executive Law, for the above-named agency. As such, I am authorized to

request, receive, and review criminal history information for this agency in accordance with law.

2. Each application for a subject individual for whom a criminal history check has been submitted to DOH CHRC Unit will be authorized by me.

3. Each subject individual will be informed that the Agency identified above is authorized to request criminal history record checks and to review

the results of such checks.

4. Each subject individual will be informed that he or she has the right to obtain, review and seek correction of his/her criminal history

information

pursuant to rules and regulations of the New York State Division of Criminal Justice Services and the FBI. The signed, informed consent each

subject individual will be obtained prior to requesting a criminal history record check.

5. The results of each criminal history record check generated as a result of the CHRC Program will be used by the above-named agency

solely for the purposes authorized by law.

6. Upon information and belief, the above-named Agency, its agents, and employees are aware of and will abide by the confidentiality

requirements and all other requirements pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 4 - AUTHORIZED PERSON SIGNATURE AND NOTARY ACKNOWLEDGMENT

I understand that my role in the Criminal History Record Check (CHRC) Program is granted for the sole purpose of performing responsibilities as

the Authorized Person for this Agency related to the request, receipt and review of criminal history record checks pursuant to provisions of Article

28-E of the Public Health Law and Section 845-b of the Executive Law. I agree to use this application solely in support of that responsibility. I

further understand that the results of the criminal history record checks will only be used and disseminated for purposes authorized by law, and I

will abide by the confidentiality requirements set forth in law.

Agency

PFI or

Name

Operating License No

Print Name of

Authorized Person

Title

Authorized

Person Signature

Acknowledgment to be completed by a Notary Public

State of ____________________________

County of ___________________________

On this _______ day of _______________, 20___, before me personally

appeared____________________________________________________

Known to me to be the same person described in and who executed the foregoing instrument, and __he duly acknowledged to me that __he

executed same.

_______________________________________________________

Notary Public

(Please sign, affix stamp and include expiration date)

Criminal History Record Check Page 2

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