\par }}{\*\ftnsepc \ltrpar \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid14438297 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\af5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 { PRIVACY POLICY ACKNOWLEDGEMENT FORM. guidelines designated by the Department of Health, and all UNAR requirements. Prints will remain active for 60 days to allow for re-employment in a licensed setting. The way will require some information, such as full name, date of birth, social security number, address, and driver's license number. \par \tab \hich\af5\dbch\af31505\loch\f5 (6) "Covered employer" means an individu\hich\af5\dbch\af31505\loch\f5 al who: Contact information for states maintaining records at the state level is provided on the State-Maintained Records listing. Last, background screenings are required if you are seeking legal guardianship consent for youth ages 12- to 17-years-old and not living in a foster/adoptive home and not receiving services. Background checks will be repeated on a regular basis; every year for the NYS Sex Offenders' Registry, every 3 years for the Criminal History File check and MVR check. The screened professions listed below require background screening at initial licensure and/or renewal of licensure. \par \tab \hich\af5\dbch\af31505\loch\f5 (2) Juvenile Records 1-800-273-TALK(8255) 195 North 1950 West 1c57826650ab74c27eb3d20fc3667d1cd66ba341e31514161927f530bbb19fc00506dde4f7f67a7cefee3ed9ded1dc99b3a4caf4dd7c5513d777f7f5c6e1bb7b Charges will be fairly assessed by the Office of Licensing as described in state law, A licensed program shall not be provided the details of any applicants screenings nor can they disclose screening results except as authorized by Utah or federal law. b175b61bc320c71aa0ecd1a17bd41e35eb16ded0dfdce3dc0fd5c7c26b50a63fd8c34f2643b0a285d7a00c1feee1c3417730b2f56b50866fede1dbb5fe28685b You may be eligible to request a conditional clearance per R501-14-7-2if: The following information is required in order to request a conditional approval: If you meet the above criteria, you may request a conditional approval here. A potential IPs background check must be completed, and a fingerprint appointment scheduled (when applicable), before working with eligible Medicaid clients. }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) child abuse or neglect findings described in Section 78A-6-323; The applicant must also complete the Medical Cannabis Production Establishment Criminal Background Receipt form. \par d398af2571687c182716f094313a60dc6985876a2ec3ccb3751ab927e76b13f714a10bd7dc43945a5e1eaf579063894be530c616cd2714a5124538c5d253dfb1 4757e8d3f729e245eb2b260a0238fd010000ffff0300504b030414000600080000002100b6f4679893070000c9200000160000007468656d652f7468656d652f \par \tab \hich\af5\dbch\af31505\loch\f5 (2) The covered provider must ensure that the engaged covered individual: Box 570, Jefferson City, MO, 65102. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) by contract; \par \tab \hich\af5\dbch\af31505\loch\f5 In addition: \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 Notice of Continuation: January 29, 2018}{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 195 North 1950 West \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table 3D effects 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Contemporary;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Elegant;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Professional; \par \par \tab \hich\af5\dbch\af31505\loch\f5 (8) A covered provider that provides services in a residential setting mu\hich\af5\dbch\af31505\loch\f5 submit live scan fingerprints. {\f535\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\f536\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f537\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f869\fbidi \froman\fcharset238\fprq2 Cambria Math CE;} \par \tab \hich\af5\dbch\af31505\loch\f5 (F) 76-10-1301 to 1314, Prostitution; and Providers do not need to submit payment if there is a fee indicated. \lsdpriority65 \lsdlocked0 Medium List 1 Accent 3;\lsdpriority66 \lsdlocked0 Medium List 2 Accent 3;\lsdpriority67 \lsdlocked0 Medium Grid 1 Accent 3;\lsdpriority68 \lsdlocked0 Medium Grid 2 Accent 3;\lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 3; Live scan operator will sign and return a copy of the form to be uploaded into DACS by the screening agent. Headquarters Multi-Agency State Office Building 195 North 1950 West Salt Lake City, Ut 84116. Online Background Check Authorization form for Applicants. e Department determines an individual is not eligible for direct patient access based upon the criminal background screening and the individual disagrees with the information provided by the Criminal Investigations and Technical Services Division or court Until the Office of Licensing has approved the screening, an applicant shall have no direct access to a child or vulnerable adult. Mail the Authorization form, fingerprint card, and certified check or money order (personal checks are not accepted) for $65.00 made {\fhimajor\f31533\fbidi \fswiss\fcharset177\fprq2 Calibri Light (Hebrew);}{\fhimajor\f31534\fbidi \fswiss\fcharset178\fprq2 Calibri Light (Arabic);}{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;} Employee Background Screening. In the interest of professionalism, public trust and safety for families and individuals, Utah code requires that all persons associated with a licensed facility (owner, director, governing body, employee, agent, provider, contractor or volunteer) who has or will have direct access to children and/or vulnerable adults must pass a criminal background screening. 1-801-587-3000 {\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);} \hres0\chhres0 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'02\'03. Most states require that changes to Identity History Summary information be processed through their respective state centralized agency (State Identification Bureau) before any changes can be made to your information. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) As required by Utah Code Subsection \hich\af5\dbch\af31505\loch\f5 The process for submitting these applications is as follows: Application: Fill out the application of the adoptive parent for the one-time clearance. {\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\fbiminor\f31507\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f529\fbidi \froman\fcharset238\fprq2 Times New Roman CE;} Call: (801) 538-4242 \par \tab \hich\af5\dbch\af31505\loch\f5 (a) means an individual: Utah Domestic Violence BCCU website For background policy questions: Individual Providers (IP) 866-214-9899 Medicaid Contracted Home Care Agency (HCA): 360-725-2560 Nursing Home, Assisted Living, Adult Family Home and Enhanced Services Facilities: 360-688-0715 This information will be used by the Department of Human Services, Office of Licensing to determine my eligibility to have direct access to a child or vulnerable adult. 1-800-371-7897 1-800-273-TALK(8255) Salt Lake City, UT 84116. While it can be somewhat scary at first, it is actually a good thing. \lsdpriority60 \lsdlocked0 Light Shading Accent 3;\lsdpriority61 \lsdlocked0 Light List Accent 3;\lsdpriority62 \lsdlocked0 Light Grid Accent 3;\lsdpriority63 \lsdlocked0 Medium Shading 1 Accent 3;\lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 3; {\*\colorschememapping 3c3f786d6c2076657273696f6e3d22312e302220656e636f64696e673d225554462d3822207374616e64616c6f6e653d22796573223f3e0d0a3c613a636c724d 1-855-323-DCFS(3237) Background Screening. 1-800-371-7897 \par \tab \hich\af5\dbch\af31505\loch\f5 (xi) volunteer as defined by \hich\af5\dbch\af31505\loch\f5 department rule. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 3; \lsdpriority61 \lsdlocked0 Light List Accent 4;\lsdpriority62 \lsdlocked0 Light Grid Accent 4;\lsdpriority63 \lsdlocked0 Medium Shading 1 Accent 4;\lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 4;\lsdpriority65 \lsdlocked0 Medium List 1 Accent 4; dhslicensing@utah.gov. Attn: CHRC, Hawaii Criminal Justice Data Center, Department of the Attorney General, 465 South King Street, Room 101, Honolulu, HI 96813. \par \tab \hich\af5\dbch\af31505\loch\f5 (i) any felony or class A convi\hich\af5\dbch\af31505\loch\f5 ction under Utah Code. If you choose not to use a DCFS Live Scan, you may submit two fingerprint cards. b01d583deee5f99824e290b4ba3f364eac4a430883b3c092d4eca8f946c916422ecab927f52ea42b89a1cd59c254f919b0e85e6535d135a8de20f20b8c12c3b0 This screening requires a separate application (see below). Background Screening Application - Youth Transport Company employeees only. If you believe your Identity History Summary contains inaccurate or incomplete information, you have two options for requesting a change or correction: Option 1: Contact the agency or agencies that submitted the information to the FBI. f9c6b10f3e4ebfe3566c25ab6b763a8792c9f14e7f7308b7dbd50c195f904fbfa919a175fa04431dd9cf58b73dcd6d4fe3ffdff73487f6f36d2773a8dfb8ed64 6bb6913e68dd1250b2d721614c6693683a48b4b783ca48fa58178ce620a157f65158741d2c3a4afdd6557b2c805ae115f8c1edc1cff49e1f06200242701e07cd 493c1b9426881fd2fc08bc6eda7c0ca52e7105c0633a3f37818f08f480102f4ea33c16a0c308ee835a9fc4c82a60ea5db8e375c32dff5d658fc1be7c61d1b8c2 9cb2400825e982c78ec7a27cc0c8992416c9d8b2a755fbf74cd25442a820166c2cd933f79e3be372bd1f07b5c3989ca74aaff2422b24eb1b475da5df374fd9ad {\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0; \par \tab \hich\af5\dbch\af31505\loch\f5 (a) As required by Utah Code Subsection 26-21-204(4)(a)(ii)(E\hich\af5\dbch\af31505\loch\f5 ), juvenile court records shall be reviewed if an individual or covered individual is: Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 8;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 9;\lsdsemihidden1 \lsdlocked0 index 1;\lsdsemihidden1 \lsdlocked0 index 2; I understand that I may request to review any results of this inquiry and understand that UCA 53-10-108 does not allow the. \lsdpriority48 \lsdlocked0 Grid Table 3 Accent 5;\lsdpriority49 \lsdlocked0 Grid Table 4 Accent 5;\lsdpriority50 \lsdlocked0 Grid Table 5 Dark Accent 5;\lsdpriority51 \lsdlocked0 Grid Table 6 Colorful Accent 5; Salt Lake City, Ut 84116, DLBC Contact Info 195 North 1950 West This form must be presented to the live scan agent AFTER DACS application is submitted in order for the prints to be linked to the applicant in DACS. d. All employees who require screening must: i. sign a criminal background screening authorization form; ii. \lsdpriority49 \lsdlocked0 List Table 4 Accent 5;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 5;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 5;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 5; Us department of justice criminal background check. Your SSAN is needed to keep records accurate because other people may have the same name and birth date. \par \tab \hich\af5\dbch\af31505\loch\f5 (E) 76-10-1201 to 1229.5, Pornographic and Harmful Materials and Performances; : 43003 Filed: 06/15/2018 10:31:45 AM. I understand that my personal information including name, DOB, SSN and fingerprints will be used for the purpose of . \leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'03(\'04);}{\levelnumbers\'02;}\rtlch\fcs1 \af0 \ltrch\fcs0 \hres0\chhres0 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0 Purpose. . \par \tab \hich\af5\dbch\af31505\loch\f5 (b) As required by Utah Code Subsection 26-21-204, if an individual or covered individual has a warrant for arrest or an arrest for any of the identified offenses in R43\hich\af5\dbch\af31505\loch\f5 \par \tab \hich\af5\dbch\af31505\loch\f5 (a) cause physical or mental harm; Sexual Violence Crisis Line The DSS will pay any fees required. \par \tab \hich\af5\dbch\af31505\loch\f5 (v) licensing and certification records of individuals licensed or certified by the Division of Occupational and Professional Licen\hich\af5\dbch\af31505\loch\f5 sing under Title 58, Occupations and Professions; and 0000000000000000000000000000000000000000000000000105000000000000}}. Instead, the FBI accesses the states system for authorized purposes to review the record. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) by employmen\hich\af5\dbch\af31505\loch\f5 t; This includes SAS & DSPD Certified Providers. 2f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73848f4d0ac2301484f78277086f6fd3ba109126dd88d0add40384e4350d36 67a97b37e576b7b96ea74f28aa0418bcb09fa3ea5ea12018d4cac92c6a8af17e1a56393b1fb56bc776811fa07695226164fdd656ed8edd8a1ae19c0e066f54f9 \par \tab \hich\af5\dbch\af31505\loch\f5 (1) Convictions or Pending Charges \lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 4;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 5;\lsdpriority47 \lsdlocked0 List Table 2 Accent 5;\lsdpriority48 \lsdlocked0 List Table 3 Accent 5; earance for a covered individual. \sbasedon0 \snext15 \slink16 endnote text;}{\*\cs16 \additive \rtlch\fcs1 \af5\afs20 \ltrch\fcs0 \f5\fs20 \sbasedon10 \slink15 \slocked \ssemihidden \styrsid14438297 Endnote Text Char;}{\*\cs17 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \super \sbasedon10 The child care staff member needs to keep a copy of their letter for any future child care employers. he covered employer and the individual explaining the action and the individual's right of appeal as defined in R432-30. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 6; The Live Scan Fingerprint Authorization Form can then be taken to any Utah \par \tab \hich\af5\dbch\af31505\loch\f5 (a) Clergy; Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List 3; \lsdpriority72 \lsdlocked0 Colorful List Accent 6;\lsdpriority73 \lsdlocked0 Colorful Grid Accent 6;\lsdqformat1 \lsdpriority19 \lsdlocked0 Subtle Emphasis;\lsdqformat1 \lsdpriority21 \lsdlocked0 Intense Emphasis; About. All U.S. employers must properly complete Form I-9 for each individual they hire for employment in the United States. Record Challenge Form Download. \par \tab \hich\af5\dbch\af31505\loch\f5 (iii) potential risk to patients or residents. After you do this, you will receive a Livescan Authorization Form to take with you when you get fingerprints done, Use this form if you provide respite care or babysitting for a foster provider and do not live in the foster home, Fill out the form completely, following the instructions on page 2 of the form, Make sure to include the name of the foster provider and licensor in the appropriate spaces and sign the form. Child Abuse/Neglect \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 2;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 3;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 4; Sexual Violence Crisis Line 7ce8306e3b99fc70e5e3743265f3027d8d3af0c80e7af4b14f72f0d46749289dca0dc527421ffc08f83db398c0a092d3279eb838055cc5f0a8ca1c4c60e1228e 000000000000000000009d0a00007468656d652f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73504b050600000000050005005d010000980b00000000} We strongly believe that health is critical for enjoying a prosperous life. Applicant must provide all known substantiated findings of abuse, neglect or exploitation or any felony criminal history to the department upon submission of the criminal history screening application. {\*\latentstyles\lsdstimax376\lsdlockeddef0\lsdsemihiddendef0\lsdunhideuseddef0\lsdqformatdef0\lsdprioritydef99{\lsdlockedexcept \lsdqformat1 \lsdpriority0 \lsdlocked0 Normal;\lsdqformat1 \lsdpriority9 \lsdlocked0 heading 1;

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