APPLICATION PROCESS REGARDING LAST NAME CHANGE:

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1 APPLICATION PROCESS The following information and instructions are very important and must be followed to the letter in order that we can successfully complete the process with each employee. Fill out COMPLETELY the Background Study/Driver s License Form before submitting it to Linda. Forms not completely filled out may be returned to PD for completion. A CLEAR copy of the Driver s License or acceptable identification must accompany form. Do not fax a copy of the DL because 99% of the time the picture is not clear. You, or your new hire, may take a picture of their Driver s License or scan it and it to Linda: linda@drccinfo.org. They must sign the form and get a copy of the Background Privacy Notice. Linda will verify the information and then begin the Background Study process. If fingerprinting is needed, she will send you an verifying that fingerprinting/photo is necessary to finish the process. Fingerprinting and photo completion in Duluth will be done at the Main Office (Linda s room). Hours available are Monday Thursday, 8:30am 4:30pm and Friday, 8:30am 12:30pm , ext PD s must call Linda to set up a time to come in. Fingerprinting and photo completion on the Range will be done at the IHFS-Range office. PD s must call the IHFS-Range program to set up a time The new hire must bring their acceptable identification with them. Employees who have been fingerprinted from another provider will simply be verified within the system as being okay to hire. There will be no need for fingerprinting. Linda will verify this and notify you. Once the entire process has been completed and the employee cleared, Linda will notify you they are eligible for hire. Please wait for the clearance before the person comes to the Program for any paperwork or training. REGARDING LAST NAME CHANGE: If an employee has changed their last name, please let Linda know as soon as possible as the change must be entered into the DHS Background Study system in a timely period. Required information: Previous Last Name, Current Last Name, Middle Name, First Name and Date of Change. 1/11

2 DRCC Background Study Identity Information: to be filled out by Program Director / Office Document: Document Number: PROGRAM: Copy of Document must accompany this form. Issuing Authority: Expiration Date: Personal and Demographic Information First name Middle name Last name Suffix Social Security Number Gender Birthdate Birthplace (State) Race Eye Color Hair Color Height Weight Phone Phone Type (Cell/Home) address Permanent/Physical Address (shown on form of Identification being used) Street address City State Zip Code County Check box if permanent/physical address and mailing address are the same. Mailing Address Street address City State Zip Code County Prior Out-Of-State Addresses (within the last 5 years) City/State Date Range from (yr) to (yr) City/State Date Range from (yr) to (yr) City/State Date Range from (yr) to (yr) The individual reports that they have not lived out of state during the specified time frame. Maiden Names and Other Known Names Other first names you have used Other last names you have used The individual reports that they have not been known by any other names. The undersigned hereby authorizes to submit a MNDHS Background Study Fingerprint and Photo Authorization. Employee Signature (This form MUST be legibly signed) Date 2/11

3 DISCLOSURE FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES Please Read Carefully Before Signing the Authorization DISCLOSURE In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, DRCC ( the Company ) may request and rely upon one or more Motor Vehicle Record reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc. IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr., Suite 410, Beachwood, OH 44122; or phone: ; or website: For explanation purposes: a consumer report is a written, oral or other communication of any information by a consumer reporting agency to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. DRCC will only be running a Motor Vehicle Record report. Under the FCRA, before the Company can obtain a consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA. 3/11

4 AUTHORIZATION I have read and understand the foregoing Disclosure, and authorize DRCC to obtain and rely upon the Motor Vehicle Report record concerning me, obtained from IntelliCorp Records, Inc. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in their decision about me. I also consent to have any legally required notices sent electronically. Printed Name Applicant Signature Date Parent or Legal Guardian Signature (for searches conducted on minors under the age of 18) Date You may request a free copy of any consumer report or investigative consumer report we obtain on you by checking the box. 4/11

5 Para informacion en español, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W, Washington, DC You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your creditworthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. 5/11

6 Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at OPTOUT. ( ). You may seek damages from violators. If a consumer reporting agency, or in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active military personnel have additional rights. For more information, visit States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact: TYPE OF BUSINESS: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. CONTACT: a. Consumer Financial Protection Bureau 1700 G Street NW Washington, DC b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: b. Federal Trade Commission: Consumer Response Center FCRA Washington, DC (877) /11

7 2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25 A of the Federal Reserve Act a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN c. FDIC Consumer Response Center 1100 Walnut Street, Box # 11 Kansas City, MO c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC Creditors Subject to Packers and Stockyards Act, Nearest Packers and Stockyards Administration 1921 area supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8 th Floor Washington, DC Brokers and Dealers Securities and Exchange Commission 100 F Street, N.E. Washington, DC Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Protection Credit Associations 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above Farm Credit Administration 1501 Farm Credit Drive McLean, VA FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center FCRA Washington, DC (877) /11

8 MINNESOTA DEPARTMENT OF HEALTH LICENSED FACILITIES SUPPLEMENTAL NURSING SERVICES AGENCIES, EDUCATIONAL PROGRAMS, TEMPORARY EMPLOYMENT AGENCIES, PROFESSIONAL SERVICES AGENCIES BACKGROUND STUDY PRIVACY NOTICE Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following: 1. Purpose and intended use of the information: Minnesota Statutes, section , requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS. 2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study. 3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified. 4. Known consequences that will arise from refusing to supply the requested information: Only items identified as optional may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services. 5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The Page 1 of 2 07/05/12 8/11

9 Page 2 information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent. 6a. If CURRENT background study results in a disqualification that is set aside upon reconsideration: If you are disqualified as a result your background study, and you request reconsideration and your disqualification is set aside for the program/agency that initiated the current background study, subsequent background studies initiated by other programs/agencies may result in the disqualification being set aside for other programs/agencies when the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C.15, subdivision 1 or 2; 2. the program that initiates the subsequent background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside; 3. the commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. the previous set aside was not limited to a specific person(s) receiving services. If the above criteria are met, the notice of disqualification sent to the program/agency that initiates the subsequent background study will state that you are disqualified and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. ( 245C.22, subd. 5) 6b. If a PREVIOUS background study resulted in disqualification that was set aside: If you were the subject of a previous background study which resulted in your disqualification, and your disqualification was set aside upon reconsideration, DHS will review the information in your record in connection with your current background study and determine whether the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C.15, subdivision 1 or 2; 2. the program that initiated the current background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside; 3. the commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. the previous set aside was not limited to a specific person(s) receiving services. If the above criteria are met, the notice of disqualification sent to the program/agency that initiated the current background study will state that you are disqualified and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. ( 245C.22, subd. 5) Page 2 of 2 07/05/12 9/11

10 ACCEPTABLE FORMS OF IDENTIFICATION FOR DHS BACKGROUND STUDIES Entities that initiate background studies are required by law to verify the background study subject s identity in NETStudy 2.0. This is a summary of acceptable forms of identification to be used for DHS background studies. Primary Identification Document When a background study subject has a valid* picture identification listed below use this document for identity verification: State Issued Driver s License the issuing authority must be a U.S. state or territory State-Issued Identification Card the issuing authority must be a U.S. state or territory U.S. Passport or U.S. Passport Card *Valid documentation: Only unexpired, original documentation is acceptable, except when a background study subject presents an acceptable receipt for a primary or secondary identification document. There are three types of acceptable receipts: 1. A receipt showing that the subject has applied to replace the primary or secondary identification document; 2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and photograph of the individual; 3. The departure portion of Form I-94/I-94A with a refugee admission stamp. Secondary Identification Document If a background study subject does not have a valid picture identification listed above, the following secondary identification documents (consistent with federal employment requirements and the I9 form) may be used for identity verification: School ID card that includes a photograph Voter s registration card U.S. military card or draft record Military dependent s ID card U.S. Coast Guard Merchant Mariners Document (MMD) Card Native American tribal document Driver s license issued by a Canadian government authority Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Foreign passport that contains a temporary I-551 stamp or temporary I551 printed notation on a machinereadable immigrant visa (MRIV) 1 10/11 Updated: 3/27/2015

11 Employment Authorization Document (Card) that contains a photograph (Form I-766) Foreign passport with Form I-94 or Form I-94A, Arrival/Departure Report bearing the same name as the passport and containing an endorsement of the alien s nonimmigrant status that authorizes such alien to work for a specific employer incident to this status. This document may only be used if the period of endorsement has not yet expired. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I94 or Form I94A showing nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI Foreign passport with special documents issued by the Commonwealth of Northern Mariana Islands (CNMI) Foreign passport that contains a temporary I-551 stamp or temporary I551 printed notation on a machinereadable immigrant visa (MRIV) Exceptions People Under Age 18 People under 18 who are unable to present a picture identification document listed in the Primary Identification Document section may present the following acceptable secondary identification documents: School record or report card Clinic, doctor, or hospital record Day-care or nursery school record Legal References Information required to be provided by background study subjects; See Minnesota Statutes, section 245C.05, subd. 1. Information required to be verified by the entity initiating the background study; See Minnesota the issuing authority must be a U.S. state or territory Statutes, section 245C.05, subd. 2 (a). 2 11/11 Updated: 3/27/2015