14328 OhioHealth Riverside Methodist Volunteers VOLUNTEER INFORMATION

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1 14328 OhioHealth Riverside Methodist Volunteers VOLUNTEER INFORMATION APPLICANT S FULL NAME Any Other Names Used Social Security No. / / Date of Birth 1 / / Address: Current Address City State Zip Driver s License State Address on D.L. RN Volunteer Program Candidates Only: D.L. Number Please proved any current professional licenses, certification, or registries you may hold. Name as it appears on license/certification/registry (Provide if you prefer to receive information via .) Type State/Region/Issuing Organization Country Number Type State/Region/Issuing Organization Country Number *Before answering the question below, you MUST carefully read the following information: Do not report any conviction which state law allows you to lawfully deny, as set forth in the state notices that you must review before answering. You are not required to disclose minor violation or infractions. A conviction will not necessarily be a bar to employment. This information will be used to determine if the conviction is related to the job sought. Factors such as age, severity, and nature of the offense(s), etc. will be considered. Failure to honestly respond may result in discontinued consideration or termination of employment. You confirm that you have read the state notices above and confirm that the information you provide is true and accurate. Have you ever been convicted of, plead guilty, no contest or nolo contender, to a misdemeanor or felony? If you answer Yes, you must provide details. Yes No (Please attach a separate sheet of paper to provide additional entries.) Offense County State When Offense County State When Please provide all locations where you have resided for the past seven (7) years, starting with your current residency. (Please attach a separate sheet of paper to provide additional entries.) 1. City: State: Date From: Date To: 2. City: State: Date From: Date To: 3. City: State: Date From: Date To: 4. City: State: Date From: Date To: STATE LAW NOTICES California applicants or employees only: Please mark this field to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. California applicants or employees only: A copy of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW is also being provided to you. info@precheck.com Nevada Private Investigator License #1618 ph: fax:

2 Colorado applicants or employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be present and unacceptable risk of theft or other dishonest behavior in the job for which you are being considered/currently occupying. Connecticut applicants or employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be Maryland applicants or employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be Massachusetts applicants or employees only: The precise nature and scope of any investigative consumer report (which commonly includes information regarding your character, general reputation, personal characteristics, and mode of living) will be the same types of information described above. You have a right to have a copy of any investigative consumer report upon request from PreCheck, Inc.; 3453 Las Palomas Rd.; Alamogordo, NM 88310; Minnesota applicants or employees only: You have the right to request a complete and accurate disclosure of the nature and scope of any consumer report from PreCheck, Inc.; 3453 Las Palomas Rd.; Alamogordo, NM 88310; Place an X here for a disclosure to be sent to you. Place an X here for a free copy of your consumer report to be sent to you. Montana applicants or employees only: You have a right to request from Company disclosures of the nature, scope, and substance any investigative consumer report. New Jersey applicants or employees only: The precise nature and scope of any investigative consumer report (which commonly includes information regarding your character, general reputation, personal characteristics, and mode of living) will be the same types of information described above. You have a right to have a copy of any investigative consumer report upon request from PreCheck, Inc.; 3453 Las Palomas Rd.; Alamogordo, NM 88310; ; New York applicants or employees only: Company may request or utilize subsequent consumer reports (other than investigative consumer reports) on you throughout your employment. Upon request, you will be informed whether or not a consumer report was requested, and if such report was requested, informed of the name and address of the CRA that furnished the report. Upon written request, you will be informed whether or not an investigative consumer report was requested, and if such report was requested, the name and address of the CRA to whom the request was made. Your written request should be made to Company. Upon furnishing you with the name and address of the CRA, you will also be informed that you may inspect and receive a copy of such report by contacting that agency. Please mark this field to receive a copy of Article 23-A that will be presented once you complete this process:. Oklahoma applicants or employees only: Mark an X here if you would like to receive a free copy of your report. Oregon applicant or employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be Washington State applicants or employees only: You have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of any investigative consumer report we may have requested. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. Any requests under this paragraph to the CRA should be made to PreCheck, Inc.; 3453 Las Palomas Rd; Alamogordo, NM 88310; , It the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be Vermont applicant or employees only: If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be I have read and understand the above information and assert that all information provided by me is true and accurate. By signing below, I agree that my present employer may be contacted for verification of employment. Signature: Date 1 The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. This information is necessary for the proper processing of a consumer report. info@precheck.com Nevada Private Investigator License #1618 ph: fax:

3 14328 OhioHealth Riverside Methodist Volunteers VOLUNTEER AUTHORIZATION ACKNOWLEDGEMENT AND AUTHORIZATION I acknowledge receipt of the separate document entitled BACKGROUND CHECK DISCLOSURE and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigate consumer reports by OhioHealth or affiliate ( OhioHealth ) at any time after the receipt of this authorization and throughout my employment, volunteer appointment, placement at OhioHealth with a staffing agency, contract for services, or privileges, if applicable. I consent to and authorize OhioHealth throughout the term of my employment, volunteer appointment, placement, or contract, to share any consumer report received with a related entity, or, if applicable, to share my report for business reason including placing me at certain work sites, etc. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by PreCheck, Inc., 3453 Las Palomas Rd.; Alamogordo, NM [ ], another outside organization acting on behalf of OhioHealth, and/or OhioHealth itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. I understand, to the extent permitted by law, this authorization will remain in effect throughout my employment, volunteer appointment, placement or contract. By signing below, I confirm that I have read and understand the above information and that I provide my consent. Signature: Name: Date DOB Last four digits of SSN info@precheck.com Nevada Private Investigator License #1618 ph: fax:

4 14328 OhioHealth Riverside Methodist Volunteers VOLUNTEER DISCLOSURE APPLICANT S FULL NAME Any Other Names Used Social Security No. / / Date of Birth / / Current Address City State Zip Driver s License State D.L. Number Address on D.L. DISCLOSURE REGARDING BACKGROUND INVESTIGATION OhioHealth or affiliate ( OhioHealth ) may obtain information about you from a consumer reporting agency made in connection with your employment, volunteer appointment, placement at OhioHealth with a staffing agency, contract for services, or privileges. Thus, you may be the subject of a consumer report and/or and investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews. These reports may contain information including but not limited to: verification of identification, and/or Social Security number; checks of criminal history; verification of employment; verification of education; credentials and/or licensures; credit history (to the extent necessary for the position), drug and/or alcohol testing, sanctions/exclusions from Medicare/Medicaid and/or other information on my background or history. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM [ ] or another vendor of OhioHealth. Your authorization allows OhioHealth to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment, volunteer appointment, placement at OhioHealth, or contract to the extent permitted by law. info@precheck.com Nevada Private Investigator License #1618 ph: fax:

5 State Specific Notices * California employees/residents: You need not disclose any referral to, and participation in, any pretrial or post trial diversion program, or any misdemeanor convictions for which probation has been successfully completed and discharged. Do not list any marijuana-related misdemeanor convictions over two years old, or felony marijuana convictions under California Health and Safety Code Section (c) which occurred prior to * Connecticut employees/residents: You need not disclose any conviction record that has been erased pursuant to sections 46b-146, 54-76o or a of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nolled, or a criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased within the meaning of these three sections may consider such events to have never occurred and may so swear under oath. * Massachusetts employees/residents: An applicant for employment with a sealed record on file with the commissioner of probation may answer no to the above with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer no to the above with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. You may exclude information regarding first convictions for the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or a conviction for any misdemeanor where the conviction occurred or any prison sentence ended five or more years ago whichever date is later, unless you have been convicted of another offense within the last 5 years. * Philadelphia, PA employees/residents: You may exclude convictions that occurred more than 7 years from the date of the inquiry. Any period of incarceration should not be included in the calculation of the 7 year period. * San Francisco, CA employees/residents: You may exclude convictions that occurred over seven years ago and a conviction or any other determination or adjudication in the juvenile justice system, or information regarding a matter considered in or processed through the juvenile justice system. * Washington State employees/residents: You may exclude convictions that occurred over ten years ago. * Seattle, WA employees/residents: In addition to the above, you may exclude a criminal conviction that has been the subject of a certificate of rehabilitation or other equivalent procedure based on a finding of the rehabilitation. * Georgia: Applicants may exclude convictions discharged under Georgia s First Offender Programs. * Nevada: Applicants are not required to disclose misdemeanor convictions which resulted in imprisonment older than 10 years. * New York: Applicants for job positions may exclude an adjudication as a youthful offender. * Ohio: Applicants with a conviction for a minor misdemeanor violation involving marijuana does not constitute a criminal record and does not need to be reported by the person so convicted in responding to the questions on this application.

6 Para informacion en espanol, 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 identify 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 credit-worthiness 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. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed

7 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 a 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 phone 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 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 duty military personnel have additional rights. For more information, visit

8 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. b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau: 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 CONTACT: a. Bureau of Consumer Financial Protection 1700 G Street NW Washington, DC b. Federal Trade Commission: Consumer Response Center FCRA Washington, DC (877) a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 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 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions 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 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 Department of Transportation 400 Seventh Street SW Washington, DC Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 1925 K Street NW Washington, DC Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production 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)