Long Term Care/Home Health Care Worker Background Check

By signing this form, I consent to the submission of a request for a criminal records check for long-term care worker / home health care worker as required by Senate Bill 160.  The request will be submitted by:__________________.

I also attest to the following:

1. I have not been convicted of or pleaded guilty to any of the crimes that would disqualify me from working with older adults under S.B. 160.
2. I understand and agree that if I am found to have a record of any of those crimes, I will not be hired for work with older adults or, if I have already been hired, my employment will be terminated.
3. I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment.

_____________________                     __________________________

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