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Series 401.5P - Informed Consent - Pre-Employment Background Check

Adopted: June 1995
Revised: July 2014

INFORMED CONSENT - PART I

Authorization, Rights and Disclosures

I understand that Independent School District 196 is seeking background check data in accordance with Minnesota Statute 299C.60 et. seq. (the Minnesota Child Protection Background Check Act), Minnesota Statute 123B.03, and Minnesota Statute 13.05, subd. 4, as part of my application for employment or ongoing service with District 196. I acknowledge that a background check and the information requested on this consent form are required in order for me to be employed by the District and my refusal to provide the information requested will result in my ineligibility for employment with the District. I also understand that violations of the law revealed through a background check may result in the revocation of a conditional offer of employment and/or the termination of my employment with the District.

I acknowledge that District 196 has informed me of my rights under Minnesota Statutes 299C.60 et. seq., (the Minnesota Child Protection Background Check Act) including the following:

1.   The right to be informed that the district will request a background check on children’s service workers:

      a.   for purposes of employment or continuation of employment; and

b.   to determine whether the children’s service worker has been convicted of any children’s service background check crime.  District 196 will also check for other crimes not encompassed by the Minnesota Child Protection Background Check Act.

2.   The right to be provided by District 196, before any adverse action is taken based in whole or in part on the information contained in the consumer report, with a copy of the report, the name, address and telephone number of the reporting agency and a summary of my rights under the Fair Credit Reporting Act;

3.   The right to obtain from the Bureau of Criminal Apprehension any record that forms a basis for a report issued under Minnesota Statutes 299C.60 et. seq.;

4.   The right to challenge the accuracy and completeness of any information contained in the report or record under the relevant provisions of the Data Practices Act, and

5.    The right to be informed by District 196 if my application is not to be considered for employment or if my opportunity to continue as an employee has been denied because of the response to the background check.

I understand that District 196 may use a consumer reporting agency to conduct a criminal and motor vehicle background check and to issue a report based upon the results of that check.  I understand that, upon my written request, additional information regarding the nature and scope of the report will be provided by the consumer reporting agency.  I further understand that I am entitled to request a copy of the consumer report.

I hereby authorize Independent School District 196 and/or its agents to retrieve information from appropriate personnel, institutions or agencies (including, but not limited to, the Minnesota Bureau of Criminal Apprehension, similar agencies in other states, counties, state motor vehicle departments, the FBI and consumer reporting agencies) concerning my background relative to any criminal history or motor vehicle violations. I hereby authorize District 196 to utilize all information contained herein, to request and receive my fingerprints, and to disclose the information and fingerprints to the above-described personnel, institutions or agencies, to perform a background check on me.  I authorize these personnel, institutions or agencies to disclose criminal history or motor vehicle violations information, including arrest and disposition data, to the District 196 Coordinator of Human Resources and/or the coordinator’s designee.

I release any individual, institution, agency and District 196, including its officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may result because of this authorization and resulting background check.

 

INFORMED CONSENT - PART I (Continued)

Authorization, Rights and Disclosures

I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to The McDowell Agency and Independent School District 196 pursuant to Minnesota Statute 123B.03 for the purpose of employment/volunteering with Independent School District 196.  I understand The McDowell Agency is a third party vendor acting on behalf of Independent School District 196.

I acknowledge that I have read and understand all parts of this consent form.  I hereby certify that the information I have provided is true and complete and understand and agree that any false information or significant omission will be grounds for disqualification or dismissal whenever discovered by District 196.  I further acknowledge that I have received, read and understand the District 196 Pre-Employment Background Check Policy, Regulation and Procedure.

Signature: ______________________________________________ Date: _____________________       

•  A photocopy or fax copy of this consent shall serve as the original.  This consent will remain in effect for one year from the date of the signature as specified above. 

•  District 196 may, at its discretion, require volunteers and independent contractors to complete this consent and submit to a background check.

 
   

          Check here if you would like to receive a copy of the report prepared by the consumer reporting agency.

 

INFORMED CONSENT - PART II

Required Data

The following data is required to complete the background check.  The information is required solely for the purpose described in this consent and will not be used in a discriminatory manner.

Legal Name (print): _____________________________________________________________________________

                                                First                               Middle (full)                            Last

Have you used any other names in the past seven years?              Yes                          No

If yes, name used (print):                                                                                Dates used                -            

If yes, name used (print):                                                                                Dates used                -            

                                    

Date of birth: _______________ Gender (M or F): _______  Social Security number:                                     

Month/Day/Year

Home addresses for the past seven years (include temporary and/or college addresses):


Street address


City


State


ZIP


County

From
(mo/yr)

To
(m/yr)

Current:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                    Attach additional page if necessary to record all addresses in last seven years

Have you ever been charged with or convicted of a misdemeanor or felony crime?    Yes____ No____

Are any criminal charges or proceedings pending against you?                                     Yes____ No____

If yes, please explain in some detail, including what county and state, and in what year: _____________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Position applied for with District 196: 

Job title___________________or Volunteer as __________________________ at School(s)__________________________

Daytime phone                                     

Procedures/401.5P/7-09-14