utah department of health criminal background screening authorization form

The following form is for those individuals seeking to obtain a copy of their own Utah criminal history record. 7ce8306e3b99fc70e5e3743265f3027d8d3af0c80e7af4b14f72f0d46749289dca0dc527421ffc08f83db398c0a092d3279eb838055cc5f0a8ca1c4c60e1228e 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 (3) The covered provider must ensure the Direct Access Clearance System reflects the current status of the covered individual within 5 w\hich\af5\dbch\af31505\loch\f5 orking days of the engagement or termination. The DSS will pay any fees required. 1-800-273-TALK(8255) 195 North 1950 West \par \tab \hich\af5\dbch\af31505\loch\f5 (iii) any felony or class A, B or C conviction under the following Utah Codes: We strongly believe that health is critical for enjoying a prosperous life. 1-800-273-TALK(8255) Call: (801) 538-4242 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. \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) the severity of offense; and \lsdpriority48 \lsdlocked0 List Table 3 Accent 4;\lsdpriority49 \lsdlocked0 List Table 4 Accent 4;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 4;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 4; \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-7. \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) any felony, class A or B conviction under Utah Criminal Code 76-6-106(2)(b)(i)(A) Criminal Mischief - Human Life; {\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;} Sexual Violence Crisis Line \par \tab \hich\af5\dbch\af31505\loch\f5 (b) Adjudications by a juvenile court may\hich\af5\dbch\af31505\loch\f5 (Written copy must be provided to all applicants submitting fingerprints for an FBI background check. 3198720e274a939cd08a54f980ae38a38f56e422a3a641c8bbd048f7757da0f19b017cc524bd62107bd5001996509affb3fd381a89672f1f165dfe514173d985 Please direct inquiries about fingerprinting, Utah criminal records (including expungement or correction procedures) to: Utah Department of Public Safety, Bureau of Criminal Identification (BCI), 3888 West 5400 South {\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);} Exclusion from Direct Patient Access. Prints will remain active for 60 days to allow for re-employment in a licensed setting. \red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128; Some employment authorization documents issued by DHS include but are not limited to Form I-94 Arrival/Departure Record issued to asylees or work-authorized nonimmigrants (for example, H-1B nonimmigrants) because of their immigration status, Form I-571, Refugee Travel Document (PDF), an unexpired Form I-327, Reentry Permit , Form N-560 . \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Continue 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Message Header;\lsdqformat1 \lsdpriority11 \lsdlocked0 Subtitle;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Salutation; \par \tab \hich\af5\dbch\af31505\loch\f5 (11) "Engage" means to obtain one's services: ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff e. }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35. d individual prior to issuance of a provisional license, license renewal or engagement as a covered individual. \par \tab \hich\af5\dbch\af31505\loch\f5 (1) As required in Utah Code 26-21-204 the department may review relevant information obt\hich\af5\dbch\af31505\loch\f5 ained from the following sources: \par \tab \hich\af5\dbch\af31505\loch\f5 (c) as a volunteer; or \pndec\pnstart1\pnindent720\pnhang {\pntxta . Renewing your background screening is no longer necessary if you are in our DACS system and enrolled in Rapback. The background screening unit will notify the provider and the child care staff member of the results determining if they are eligible or ineligible to work or be present in a licensed, regulated, or registered child care facility. \par \tab \hich\af5\dbch\af31505\loch\f5 (15) "Resident" means an individual who receives health care services from one of the following\hich\af5\dbch\af31505\loch\f5 covered providers: overed provider must submit required information to the Department to initiate and obtain a clearance prior to the issuance of the provisional license. }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 with conditions, during an appeal process, if the covered individual can demonstrate the work arrangement does not pose a threat to the safety and health of patients or residents. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) As required by Utah Code Subsection \hich\af5\dbch\af31505\loch\f5 \par \lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 2;\lsdpriority70 \lsdlocked0 Dark List Accent 2;\lsdpriority71 \lsdlocked0 Colorful Shading Accent 2;\lsdpriority72 \lsdlocked0 Colorful List Accent 2;\lsdpriority73 \lsdlocked0 Colorful Grid Accent 2; 1-801-587-3000 RULE ANALYSIS Purpose of the rule or reason for the change: The purpose of this amendment is to modify this rule to allow fingerprinting of applicants under the age of 18, clarify the types of deniable charges and convictions, and to make technical changes that match the current process for background screening for licensed health . If the individual is not eligible for cl \par \tab \hich\af5\dbch\af31505\loch\f5 (16) "Residential setting" means a place provided by a cov\hich\af5\dbch\af31505\loch\f5 ered provider: Cannon Health Building 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 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 \par \tab \hich\af5\dbch\af31505\loch\f5 (1) Utah Code, Title 26, Chapter 21, Part 2 requires that a covered provider enter required information into the Direct Access Clearance System to initiate a clearance for each covere\hich\af5\dbch\af31505\loch\f5 Utah Domestic Violence The Utah Department of Health and Human Services is now one agency. {\flominor\f31504\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fdbminor\f31505\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;} \par \tab \hich\af5\dbch\af31505\loch\f5 (7) "Covered individual": 9cb2400825e982c78ec7a27cc0c8992416c9d8b2a755fbf74cd25442a820166c2cd933f79e3be372bd1f07b5c3989ca74aaff2422b24eb1b475da5df374fd9ad \hich\af5\dbch\af31505\loch\f5 n\hich\af5\dbch\af31505\loch\f5 existing license or deny licensure as a health care facility. 534. 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. \par \tab \hich\af5\dbch\af31505\loch\f5 (1) Convictions or Pending Charges \notabind\wraptrsp\nocolbal\sprslnsp\lytprtmet\horzdoc\dghspace120\dgvspace120\dghorigin1701\dgvorigin1984\dghshow0\dgvshow3\jcompress\viewkind1\viewscale222\viewzk2\rsidroot14438297 \fet0{\*\wgrffmtfilter 2450}\ilfomacatclnup0{\*\ftnsep \ltrpar Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Application to Become a Qualified Entity for Background Checks on Employees or Volunteers Download Utah Consent to Background Check Form Download {\*\latentstyles\lsdstimax376\lsdlockeddef0\lsdsemihiddendef0\lsdunhideuseddef0\lsdqformatdef0\lsdprioritydef99{\lsdlockedexcept \lsdqformat1 \lsdpriority0 \lsdlocked0 Normal;\lsdqformat1 \lsdpriority9 \lsdlocked0 heading 1; : 43003 Filed: 06/15/2018 10:31:45 AM RULE ANALYSIS Purpose of the rule or reason for the change: Background Screening -- Health Facilities. OR, submit the application, fee, and any other applicable documents, and request the Office send you a fingerprint authorization form for the applicant to be live scanned which will electronically submit the fingerprints. Hotlines Abuse/Neglect of Seniors and Adults with Disabilities 1-800-371-7897 Child Abuse/Neglect 1-855-323-DCFS(3237) \par \tab \hich\af5\dbch\af31505\loch\f5 (c) is\hich\af5\dbch\af31505\loch\f5 not a licensed health care facility within the state. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) by employmen\hich\af5\dbch\af31505\loch\f5 t; \sbasedon0 \snext0 index 1;}{\s31\ql \li720\ri0\sl240\slmult0\nowidctlpar\tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 Record Challenge Form Download. Fax: (850) 487-0470. {\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;} 195 North 1950 West National Suicide Prevention Lifeline West virginia university football stadium photos . National Suicide Prevention Lifeline Salt Lake City, UT 84114-8280. Multi-Agency State Office Building \widowctrl\ftnbj\aenddoc\hyphhotz950\trackmoves0\trackformatting1\donotembedsysfont0\relyonvml0\donotembedlingdata1\grfdocevents0\validatexml0\showplaceholdtext0\ignoremixedcontent0\saveinvalidxml0\showxmlerrors0 {\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;} Please submit this form before having your fingerprinting and background check done at the Mississippi State Department of Health. The following forms are for those authorized entities seeking to obtain criminal history information on employees or volunteers. GCHEXS will streamline applicant onboarding, background check processing, tracking and the notification . Crisis Line & Mobile Outreach Team . {\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; Health, Family Health and Preparedness, Licensing. 00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000ffffffffffffffffffffffff0000000000000000000000000000000000000000000000000000 A student employee moves to a non-student position. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Colorful 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Columns 1;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Columns 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Columns 3; c. UDOH is responsible for all fees associated with the criminal background checks for employees whose positions require background checks. As the applicant, you are responsible for providing this fee at the time of the live scan fingerprint appointment, The Rap Back system checks state, regional and national databases for criminal records, By submitting an application, you give consent for the Office of Licensing to monitor all relevant databases for as long as you remain licensed or associated with a licensee, The Office of Licensing will issue a screening clearance or denial, according to standards and procedures outlined in, If you receive clearance on your screening, your application will be returned to the background screening agent that submitted it. Find. \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 \s21\ql \fi-720\li720\ri720\sb480\sl240\slmult0\nowidctlpar\tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin720\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 You may contact the respective State Identification Bureau for assistance, and, if applicable, request that they provide the FBI with updates to your Identity History Summary. \lsdpriority45 \lsdlocked0 Plain Table 5;\lsdpriority40 \lsdlocked0 Grid Table Light;\lsdpriority46 \lsdlocked0 Grid Table 1 Light;\lsdpriority47 \lsdlocked0 Grid Table 2;\lsdpriority48 \lsdlocked0 Grid Table 3;\lsdpriority49 \lsdlocked0 Grid Table 4; \par \tab \hich\af5\dbch\af31505\loch\f5 (i) the Department of Human Services' Division of Child and Family Services Licensing Information Sys\hich\af5\dbch\af31505\loch\f5 tem described in Section 62A-4a-1006; he covered employer and the individual explaining the action and the individual's right of appeal as defined in R432-30. (a) . (a) Results of background screening review, as listed above in R432-35-8(1), (2), and (3), may be reviewed to determine under what circumstance, if any, the covered individual may be granted or retain direct patient access. Salt Lake City, Ut 84116, DLBC Contact Info \par \tab \hich\af5\dbch\af31505\loch\f5 (i) a nursing assistant; . \lsdpriority49 \lsdlocked0 List Table 4 Accent 1;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 1;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 1;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 1; \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toa heading;}{\s33\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs24\alang1025 \ltrch\fcs0 Division in the Department of Justice (DOJ) collects the information requested on this form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522, \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; {\f530\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\f532\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f533\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f534\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);} Covered Individuals with Arrests or Pending Criminal Charges. Signs a criminal background screening authorization form which must be available for review by the department; and . \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 HTML Keyboard;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 HTML Preformatted;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 HTML Sample;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 HTML Typewriter; ;}{\levelnumbers\'01;}\rtlch\fcs1 \af0 \ltrch\fcs0 \hres0\chhres0 }{\listlevel\levelnfc0\levelnfcn0\leveljc0 \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-8. OL will process this original clearance and continually monitor this clearance unless the screening agent separates that employee due to termination of their employment with the agency. \par \tab \hich\af5\dbch\af31505\loch\f5 (e) Patient family members; and \par \tab \hich\af5\dbch\af31505\loch\f5 (2) Juvenile Records \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Subtle 1;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Subtle 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Web 1;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Web 2; SUBJECT: Memorandum Report: State Requirements for Conducting Background Checks on Hom e Health Agency Employees, OEI-07-14-00131 In response to a congressional request, the Office oflnspector General (OIG) initiated two . \levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'02\'00. Department of Human Services, Office of Licensing to provide a copy of those results to me. Crisis Line & Mobile Outreach Team 3. (a) As required by Utah Code Subsection 26-21-204, if an individual or covered individual has been convicted, has pleaded no contest, or is subject to a plea in abeyance or diversion agreement, for the following offenses, they may not have direct patient access: (i) any felony or class A conviction under Utah Code. d0cf11e0a1b11ae1000000000000000000000000000000003e000300feff090006000000000000000000000001000000010000000000000000100000feffffff00000000feffffff0000000000000000ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff Please be aware if the fingerprint authorization form is requested, the applicant has to wait for the Office to send the form with the fingerprint authorization before they can be live scanned. This needs to be obtained prior to submitting the application to the office and the results included with the application to the Office. {\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;} One-time adoptions submitted by a non-licensed entity (adoption attorney, etc.) Medical Cannabis Production Establishment Agent Criminal Background Screening Authorization Form First Name: Last Name: I understand that my personal information including name, DOB, SSN and fingerprints will be used for the purpose of conducting a criminal history records search through any applicable state and federal databases. How do I Apply for a Concealed Firearm Permit? {\f870\fbidi \froman\fcharset204\fprq2 Cambria Math Cyr;}{\f872\fbidi \froman\fcharset161\fprq2 Cambria Math Greek;}{\f873\fbidi \froman\fcharset162\fprq2 Cambria Math Tur;}{\f876\fbidi \froman\fcharset186\fprq2 Cambria Math Baltic;} Follow the instructions on page 2 of the form for submitting the form and the payment information. }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \par \tab \hich\af5\dbch\af31505\loch\f5 (g) a home health agency; or \par \tab \hich\af5\dbch\af31505\loch\f5 (i) under the age of 28; or }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 Until the Office of Licensing has approved the screening, an applicant shall have no direct access to a child or vulnerable adult. \par \tab \hich\af5\dbch\af31505\loch\f5 (vii) dietary and food service staff; 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. \par \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table List 7;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table List 8;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table 3D effects 1;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table 3D effects 2; employee signs and dates section 5 of the application. \lsdpriority68 \lsdlocked0 Medium Grid 2 Accent 1;\lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 1;\lsdpriority70 \lsdlocked0 Dark List Accent 1;\lsdpriority71 \lsdlocked0 Colorful Shading Accent 1;\lsdpriority72 \lsdlocked0 Colorful List Accent 1; 4b0d592c9c070d8a65cd2e88b7f07c2ca71ba8da481cc52c6ce1c715e6e97818c9b48d13df49c873517d23d59085adb5dd20d6b52bd521ef2cdd5eb9246a3d8b \hich\af5\dbch\af31505\loch\f5 e\hich\af5\dbch\af31505\loch\f5 arance as defined in R432-35-8, the Department may revoke an existing license or deny licensure for healthcare services in the residential setting. used by Utah Department of Health (UDOH) to determine my eligibility for licensure as a medical cannabis product establishment owners or directors, or . The DPS must receive the authorization form with the "original" signature. {\*\rsidtbl \rsid2757304\rsid7565795\rsid14438297}{\mmathPr\mmathFont34\mbrkBin0\mbrkBinSub0\msmallFrac0\mdispDef1\mlMargin0\mrMargin0\mdefJc1\mwrapIndent1440\mintLim0\mnaryLim1}{\info{\operator Michael Broschinsky}{\creatim\yr2020\mo4\dy22\hr14\min21} \par \tab \hich\af5\dbch\af31505\loch\f5 (f) a hospice; \par \tab \hich\af5\dbch\af31505\loch\f5 (a) engages a covered individual to provide services in a private residence to: \par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a