determines there exists credible evidence that a covered individual has been arrested or charged with a felony or a misdemeanor that would be excluded under R432-35-8(1), the Department may act to protect the health and safety of patients or residents in However, if your application has been submitted for longer than three weeks, you can request a status update by emailing cbsunit@utah.gov. All Utahns should have fair and equitable opportunities to be healthy and safe. Complete social security numbers are needed for all children ages 12 and over to track their screenings in DACS. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) The dep\hich\af5\dbch\af31505\loch\f5 artment shall rely on relevant information identified in R432-35-8(1), (2), and (3) as conclusive evidence and may deny clearance based on that information. \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 7;}{\s28\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar\tqr\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \par No appeal is available if you are denied for failure to provide required information, If you close your foster care license, it is your or the screening agents responsibility to inform the Office of Licensing for removal from the ongoing Rap Back system, You are required to disclose all criminal charges, including pending charges, and all supported or substantiated findings of abuse, neglect or exploitation. Health, Family Health and Preparedness, Licensing. \par \tab \hich\af5\dbch\af31505\loch\f5 {\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;} 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. \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 \par \tab \hich\af5\dbch\af31505\loch\f5 (12) "Long-term care hospital": This screening requires a separate application (see below). \par \tab \hich\af5\dbch\af31505\loch\f5 (i) the List of Excluded Individuals and Entities database maintained by the United States Department of Health and Human Services' Office of Inspector General. s, based on information obtained through the Direct Access Clearance System, the Department shall send a Notice of Agency Action to the covered provider and the individual explaining the action and the individual's right of appeal as defined in R432-30. ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff 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, Upon completing the online application, print out the Sircon confirmation page as proof you have paid the FBI/BCI fees. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. \par \tab \hich\af5\dbch\af31505\loch\f5 (d) Resident family members; \expnd0\expndtw-3\insrsid14438297 Applicants also have the option to complete an online version of the Background Check Authorization form . \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-7. footnote text;}{\*\cs19 \additive \rtlch\fcs1 \af5\afs20 \ltrch\fcs0 \f5\fs20 \sbasedon10 \slink18 \slocked \ssemihidden \styrsid14438297 Footnote Text Char;}{\*\cs20 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \super \sbasedon10 footnote reference;}{ \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 2;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 3;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 4; The Utah Bureau of Criminal Identification is responsible for all arrest and conviction data for the State of Utah. \par \tab \hich\af5\dbch\af31505\loch\f5 (5) If the Department determines an individual is not eligible for direct patient acces\hich\af5\dbch\af31505\loch\f5 I certify that all of the personal \lsdqformat1 \lsdpriority20 \lsdlocked0 Emphasis;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Document Map;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Plain Text;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 E-mail Signature; \par \tab \hich\af5\dbch\af31505\loch\f5 This rule is adopted pursuant to Title 26 Chapter 21 Part 2. 1-855-323-DCFS(3237) The Utah Department of Health and Human Services is now one agency. The Department of Human Services, Office of Licensing will establish procedures to ensure removal of my fingerprints from applicable state and federal databases when I am no longer under their purview. {\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);} }}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta . d. All employees who require screening must: i. sign a criminal background screening authorization form; ii. For eligibility questions or concerns: 1-866-435-7414 Salt Lake City, Ut 84116, DLBC Contact Info Fingerprints: Submit 2 correctly-rolled fingerprint cards per applicant to the Office, which we will submit to the Office of Public Safety to fulfill FBI requirements. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) Clergy; exclude the individual from direct patient access if the adjudications refer to an act that, if committed by an adult, would be a felony or a misdemeanor. PRIVACY POLICY ACKNOWLEDGEMENT FORM. \par \tab \hich\af5\dbch\af31505\loch\f5 (5) "Cove\hich\af5\dbch\af31505\loch\f5 red contractor" means a person or corporation that supplies covered individuals, by contract, to: 432KB Noncriminal Justice Applicant's Privacy Rights Form 1081 Form Instructions 177KB Health Care Mississippi Background Check 192KB Regular Mississippi Background Check 171KB Applicants Living in Another State 169KB \par \tab \hich\af5\dbch\af31505\loch\f5 In addition: By submitting this authorization form, I give my permission to: 1) The . \par \tab \hich\af5\dbch\af31505\loch\f5 (vi) intervening circumstances; and Child Abuse/Neglect {\fhimajor\f31502\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0302020204030204}Calibri Light;}{\fbimajor\f31503\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;} \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; \par \tab \hich\af5\dbch\af31505\loch\f5 (17) "Volunteer" means an individual who may have unsupervised direct patient access who \hich\af5\dbch\af31505\loch\f5 is not directly compensated for providing services. 493c1b9426881fd2fc08bc6eda7c0ca52e7105c0633a3f37818f08f480102f4ea33c16a0c308ee835a9fc4c82a60ea5db8e375c32dff5d658fc1be7c61d1b8c2 Covered Employer - Direct Access Clearance System Process. \par \tab \hich\af5\dbch\af31505\loch\f5 (d) the Department of Human Services' Division of Child and Family Se\hich\af5\dbch\af31505\loch\f5 rvices Licensing Information System described in Section 62A-4a-1006; 1-855-323-DCFS(3237) Choose which box in the top left applies to you: If you are a new applicant with Utah Foster Care, mark the first box, If you are already licensed as a DCFS Foster Parent, or are residing in an Office of Licensing licensed foster home, mark the second box and include the licensor name, If you are working with an agency other that Utah Foster Care or DCFS, mark the third box and include the name of the agency, Legibly complete sections 1-5, filling in every box. \par \tab \hich\af5\dbch\af31505\loch\f5 (i) the type of offense; \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 . 000000300100005f72656c732f2e72656c73504b01022d00140006000800000021006b799616830000008a0000001c0000000000000000000000000019020000 ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff {\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;} (7) The Department may allow a covered individual direct patient access 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. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Block Text;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Hyperlink;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 FollowedHyperlink;\lsdqformat1 \lsdpriority22 \lsdlocked0 Strong; 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. Application to Become a Qualified Entity for Background Checks on Employees or Volunteers Download Utah Consent to Background Check Form Download {\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;} The process for SD state only criminal background checks includes submitting a fingerprint card, the Authorization form, and payment for each fingerprint card submitted. \par \tab \hich\af5\dbch\af31505\loch\f5 (2) A covered contractor must ensure that the covered individual, being supplied by contract to a covered provider\hich\af5\dbch\af31505\loch\f5 : \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 \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: 1-855-323-DCFS(3237) The agency will keep it on file and make it available as needed by the Office of Licensing, If a screening is denied, you and/or your background screening agent will be notified in writing, along with appeal procedures. National Suicide Prevention Lifeline The Live Scan Fingerprint Authorization Form can then be taken to any Utah I have read the attached Privacy Statement and understand my rights according to this statement. {\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);} 1-800-371-7897 Where to apply: Department of Public Safety Bureau of Criminal Identification 4315 South 2700 West Suite 1300 Taylorsville, Utah 84129 Phone: (801) 965-4445 Fax: (801) 969-7065 I need to obtain a copy of my Utah criminal history. Background screenings are required if you wish to provide foster care in your home for a child in the public welfare system. Department of Human Services Clarence H. Carter, Commissioner 505 Deaderick Street Nashville, TN 37243-1403 Contact Information. fa1e4542c2173dbfa6fffceabdbb5574940b517940d6909be8bf5c2e17589c37f49c3c3a2b260d823068f50bfd1a40e53e6edc1eb7c6ad429f06a0f91c569a71 If identifying information is missing (such as name ) your form will be returned . \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority39 \lsdlocked0 TOC Heading;\lsdpriority41 \lsdlocked0 Plain Table 1;\lsdpriority42 \lsdlocked0 Plain Table 2;\lsdpriority43 \lsdlocked0 Plain Table 3;\lsdpriority44 \lsdlocked0 Plain Table 4; 13. Once you have consent, you will need to . \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 envelope address;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 envelope return;\lsdsemihidden1 \lsdlocked0 footnote reference;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 annotation reference; It was the pioneering spirit of two remarkable individuals which would shape the future of public health in Utah for generations to come. \par \tab \hich\af5\dbch\af31505\loch\f5 (d) by other arrangement. 7aca147a3e08ad9246bbf33e1637f535c8ede6069a9a9982a6de65cf6f35430899395af5fc251c1ac363b282d811ea3717a211dcbccc25cf36fc4d32cb8a0b39 }{\field{\*\fldinst {\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 PRIVATE }{ used by Utah Department of Health (UDOH) to determine my eligibility for licensure as a medical cannabis product establishment owners or directors, or . This includes SAS & DSPD Certified Providers. \par Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities (Salt Lake City, UT) The Centers for Disease Control and Prevention (CDC) issued recommendations for vaccinating children 5 years of age and younger against COVID-19. Child Abuse/Neglect \par \tab \hich\af5\dbch\af31505\loch\f5 (v) an executive; Crisis Line & Mobile Outreach Team \tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 9;}{ \hich\af5\dbch\af31505\loch\f5 n\hich\af5\dbch\af31505\loch\f5 existing license or deny licensure as a health care facility. fa3528a6243ddf43d7c25673b85d6d0159327aec8477c360d26ee4ca4b144443115d6a8a254be5a1584bd00bc6270050408a24493db959e1259a43140f112567 \par \tab \hich\af5\dbch\af31505\loch\f5 (i) whom a covered body engages; and ere has been a failure to comply with the provisions of this chapter, or rules promulgated pursuant to this chapter, as follows: 5f3bb4f7393a33e1339260e13dc297de5396c0021dfcf119bf9ec42c46c494e8a791402952b338f48f656ca11f6d10450edc00db767cce21d5b880f7d72f2cc2 The DSS will pay any fees required. You will get an auto-generated email with a link to an online disclosure form to acknowledge. I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) does not include a student directly supervised by a member of the staff of the covered body or the student's instructor. \par \tab \hich\af5\dbch\af31505\loch\f5 (10) "Disabled individual" means an individual\hich\af5\dbch\af31505\loch\f5 This meeting requires the screening agent to verify the applicants identification and enter information contained on the identification into DACS. \par \tab \hich\af5\dbch\af31505\loch\f5 (i) types and number; DACS Information Worksheet (for use by foster parents and other adults living in foster homes) Background Screening Application - DCFS Foster/Kinship Respite Providers only. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 7;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 8;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 9;\lsdsemihidden1 \lsdlocked0 toc 1;\lsdsemihidden1 \lsdlocked0 toc 2; Purpose. If the individuals are not eligible for clearance as defined in R432-35-8, the Department may revoke a 000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000ffffffffffffffffffffffff000000000000000000000000000000000000000000000000 1-855-323-DCFS(3237) Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBIs Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. Initiate your screening by submitting the appropriate application: 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 738c1dabfb8210cbaea764ce99604be97d41bc01224e93ccc899154da5d03149c02f1b1741f0b7659bd3e7de8051d7aa47f8c246c2de40d4417e86a965c6fb68 \lsdsemihidden1 \lsdlocked0 toc 3;\lsdsemihidden1 \lsdlocked0 toc 4;\lsdsemihidden1 \lsdlocked0 toc 5;\lsdsemihidden1 \lsdlocked0 toc 6;\lsdsemihidden1 \lsdlocked0 toc 7;\lsdsemihidden1 \lsdlocked0 toc 8;\lsdsemihidden1 \lsdlocked0 toc 9; One-time Adoption Background Screening Procedure: Background screenings are required for one-time adoptions. No hard copies of clearances will be required of programs, as all clearance information will be maintained in the DACS program. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) Submits fingerprints within 15 working days of engagement. If there are criminal or abuse/neglect history items to disclose, you are asked to do so in either an uploaded document via your screening agent or if you choose not to share details with them, you may submit directly to OL at cbsunit@utah.gov, please be sure to place the DACS application number and your name and dob on your email or we will not know whose application to link the disclosure to. \par \tab \hich\af5\dbch\af31505\loch\f5 (3) If the Department denies or revokes a license, or denies direct patient access based upon arrest or criminal charges, the Department shall send a Notice of Agency Action to the covered provider and the covered 13) of the Utah State Bulletin. \lsdpriority50 \lsdlocked0 Grid Table 5 Dark Accent 3;\lsdpriority51 \lsdlocked0 Grid Table 6 Colorful Accent 3;\lsdpriority52 \lsdlocked0 Grid Table 7 Colorful Accent 3;\lsdpriority46 \lsdlocked0 Grid Table 1 Light Accent 4; In giving this authorization, I Multi-Agency State Office Building 288 North 1460 West GCHEXS will streamline applicant onboarding, background check processing, tracking and the notification . \par \tab \hich\af5\dbch\af31505\loch\f5 (c) federal criminal background databases available to the state; 1-888-222-2542 \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 Date of En\hich\af5\dbch\af31505\loch\f5 actment or Last Substantive Amendment: October 1, 2018}{\rtlch\fcs1 \af5 \ltrch\fcs0
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