Health Care Worker Background Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department’s designee, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I wish to volunteer to initiate or request a Criminal History Record Information (CHRI) check on me.

I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information and photographs related to the existence or nonexistence of any criminal record concerning me to any initiator or requestor, solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or volunteer work.

I further authorize any entity that maintains criminal records and photographs relating to me, including but not limited to a local unit of government in any state, to release those records and photographs to the ISP, FBI, or the Department.

I authorize the Department to provide any health care facility, training program, or staffing agency to which I have provided this authorization and disclosure form with a copy of my ISP CHRI and a determination of eligibility based on the FBI CHRI.

I certify that the ISP, FBI, any entity that maintains criminal records and photographs, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability that may be incurred as a result of releasing such information.

I further acknowledge that an educational entity or a health care employer shall not be liable for failure to hire or retain me as an applicant, student, employee, or volunteer if I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

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I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

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I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth, and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.