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:
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.
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.
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