Criminal History Record Information printable pdf download

Criminal History Record Information

North Carolina Department of Health and Human Services

Applicant Request For

Criminal History Record Information

Applicant Information

By my signature below, I am requesting that any results of a national criminal record check (NCRC) that are

received by the North Carolina Department of Health and Human Services (DHHS) be forwarded to me. I

understand that a NCRC will be performed if I have lived in North Carolina less than five consecutive years as of the

date below.

______________________________________________

____________________________________

Print Name

Signature

Home Mailing Address:

______________________________________________

Date:

___________________

Social Security #: ___________________

Prospective Employer Information

Name of facility:

______________________________________

Mailing address of facility where you have applied:

______________________________________

This is an optional form intended for the use of prospective unlicensed direct access employees in nursing homes, family and

adult care homes, home health, and mental health facilities in North Carolina. It should be completed by the applicant and be

sent to DHHS at the same time the fingerprint card is submitted to the State Bureau of Investigation (SBI). DHHS cannot

release the information on the criminal background check without this completed/signed form. Failure to do so will result in a

delay in the notification process. Please Note: If no criminal history record is found, only the prospective employer will be

notified and no information will be sent to the applicant.

DHHS Mailing Address:

DHHS Criminal Record Check Unit

2201 Mail Service Center

Raleigh, NC 27699-2201

ALL FORMS MUST BE RECEIVED BY USPS. DHHS WILL NOT ACCEPT FAXED OR E-MAILED FORMS .

THIS SECTION FOR DHHS USE ONLY

CHRI form received by DHHS:

___________________

DHHS authorized personnel signature:

CHRI received back from SBI:

___________________

_____________________________________________

CHRI sent to applicant:

___________________

H:CRCInfo/CHRIForm

Rev. 5/05

Criminal History Record Information

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