Background Check Authorization Form

This form authorizes the organization to obtain background information and must be completed by the applicant.

In the interest of safety and security I, the undersigned applicant, authorize Nazareth Home Inc., through its independent contractor, Administrative Office of the Courts- Records Unit (1001 Vandalay Drive, Frankfort, KY 40601, 1-800-928-6381) and /or American Databank (110 16th St, 8th Fl., Denver, CO 80202, 1-800-200-0853), to procure background information (also known as a “consumer report and/or investigative consumer report”) about me, prior to, and at any time during, my service to the organization. This report may include my driving history (if applicable to employment), including any traffic citations; a social security number verification, present and former addresses, criminal and civil history/records, Kentucky Adult Caregiver misconduct registry, the Office of Inspector General database and state nursing abuse registries.

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT located on the back of this form and certify that I read and understand both of those documents.

I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to Nazareth Home Inc., if such is made within a reasonable time from the date it was produced.

I understand for this type of employment for which I am being considered, state law requires a criminal record check as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I resided.

I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment. Such information will be used to determine whether the results of the background check reasonably bear on my trustworthiness or my ability to perform the duties of my position in a manner which is safe for Nazareth Home, Inc., residents, employees, family and visitors and in accordance with Kentucky Statute 216.789, Rules for Employment in Long-term Care Facilities.

I agree that using my electronic signature to sign this Authorization shall be valid as the original.

Clifton Background Authorization Form

Individual's Signature*
Date*
MM slash DD slash YYYY
Identifying Information for Background Information Agency (also known as “Consumer Reporting Agency”)
First Name*
Middle Name*
Last Name*
Other Names Used (alias, maiden, nickname):
Physical Street Address*
City*
State*
Zip Code*
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Please denote which purpose applies to this request.*
- Employment
- Volunteer
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Nazareth Home Inc. may obtain “consumer reports” about you from a consumer reporting agency for employment purposes. A “consumer report” is a background screening report that may contain information regarding your criminal history, sex offender registry status, credit history, employment history, education history, driving history, professional licenses, drug test results, and other information about you. It may bear upon your character, general reputation, personal characteristics and/or mode of living.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records. Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to https://www.consumerfinance.gov/learnmore/ or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington D.C. 20552.
- You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance or employment- or to take another adverse action against you- must tell you, and must give you the name, address, and phone number of the agency that provided the information.
- You have the right to know what is in your file. You may request and obtain all information about you in the files of a consumer reporting agency (you “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
  - A person has taken adverse action against you because of information in your credit report;
  - You are the victim of identity theft and place a fraud alert in your file;
  - Your file contains inaccurate information as a result of fraud;
  - You are on public assistance;
  - You are unemployed but expect to apply for employment within 60 days.
- You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage leader.
- You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See https://www.consumerfinance.gov/learnmore/ for an explanation of dispute procedures.
- Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer agency may continue to report information it has verified as accurate.
- Consumer reporting agencies may not report outdated negative information. In most cases, a consumer report agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
- Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need—usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
- You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information go to https://www.consumerfinance.gov/learnmore/.
- You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-5688).
- You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
- Identity theft victims and active-duty military personnel have additional rights. For more information, visit https://www.consumerfinance.gov/learnmore/.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.