Fillable Consent For Background Record Check Of Employee printable pdf download

CONSENT FOR BACKGROUND RECORD CHECK OF

EMPLOYEE / VOLUNTEER / INTERN

All current or perspective employees/regular volunteers/interns who work in a Department of Early Education and Care (EEC)

licensed program and who have the potential for unsupervised contact with children (as defined in EEC regulations, 606 CMR 14.00)

must complete and sign this Consent form.

To be completed by applicant:

Full Name

Last

First

Middle

Maiden or other Surnames

Date of Birth (MM/DD/YY)

Place of Birth

Gender (M/F)

Social Security # (optional)

______________

____________

___________

_____________________

Height

Weight

Eye Color

Mother’s Maiden Name

Dates and Places of Residence for the Past Seven Years:

From /To

Number & Street

City

State

ZIP

_______ ____________________________________________________________________________________________________

Please list other states in which you have resided: _________________________________

Signing this form means that you (the applicant) understand:

•

EEC will conduct a Background Record Check (BRC) which consists of both a Criminal Offender Record Information (CORI) check and a

Department of Children and Families (DCF) background record check. EEC may use this information for investigative purposes if you or

your employer is the subject of an EEC investigation.

•

The results of the DCF and CORI checks will be shared with the employer/potential employer. The employer/potential employer will

consider this information when making hiring/retention/staffing decisions.

•

The employer/potential employer will be notified if the DCF background check shows that you have been found responsible for the abuse

or neglect of a child in a supported 51B report, or if a 51A report alleging that you were responsible for the abuse or neglect of a child has

been filed and the investigation into those allegations is pending.

•

The employer/potential employer will be notified if your CORI check shows a criminal history, including convictions, pending charges,

and/or criminal arraignments that did not result in conviction.

I grant EEC permission to complete a BRC check on me and to provide the results to my employer/potential employer.

I certify the information above is correct to the best

of my knowledge.

Applicant’s Signature

Date

Employer Certification:

The applicant is applying for a position or is currently employed in an EEC licensed program. I understand that the use of this form

for any reason other than its intended purpose is unlawful.

The applicant’s identity was verified by reviewing the following form of government issued photographic identification:

_________________________________________________________ (Please keep a photocopy of said identification in file with

this application.)

Signature of Authorized Background Record Check Reviewer ________________________________ Date: ________

08/10

EmployeeVolunteerCORI

Consent For Background Record Check Of Employee

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