Michigan Medicine
Background Check
Consent & Disclosure
Michigan Medicine assures the integrity of its workforce and protects its patients in part
by conducting (directly or through third-party vendors) background checks on faculty,
staff, volunteers and, in some cases, contractors. Individual background checks currently
consist of:
•
Social Security Number verification (used to verify a person's identity)
•
International, federal, state, and local criminal records, wants and warrants
searches
•
Sex offender registry searches
•
A search of the Fraud and Abuse Control Information System (FACIS) system,
which tracks federal health care fraud and federal contractor sanctions.
Additional checks (e.g., employment history, verification of licensure and training
information, review of National Practitioner Data Bank entries, and so forth) may be
conducted in connection with any faculty appointment or Medical Staff member's
application for membership and clinical privileges, or with the employment of any other
licensed, registered or certified health professional. None of these background checks
include credit checks or other reviews of financial status or history unless your job
classification or volunteer or contractor assignment requires such a check under
applicable law or U-M policy and you have or later do separately consent to it in writing
(paper or electronic).
In addition to these general background checks, Michigan law currently requires long-
term care facilities, psychiatric facilities, home health agencies, and other health care
providers to conduct criminal background checks (including fingerprint screens) on all
employees and contractors with regular, direct access to their patients or patients'
financial, health or other identifiable information. Thus, some Michigan Medicine
employees, volunteers, contractors, or applicants must submit to fingerprint screens in
addition to the general background checks which are described further below and at
http:/ / www.michigan.gov I mdch I 0, 1607,7-132-27417-138762--,00.html.
In the event of any change in Michigan law that requires additional checks, all affected current
workforce members
and prospective applicants will be notified of the change and will be required
to consent to those additional checks as
a condition of continued employment.
BCHS-LTC-107 (Rev. 1/16)
Page 3 of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,
national origin, color, marital status, disability, or political beliefs. You may make your needs known to this Agency under the Americans with
Disabilities Act if you need assistance with reading, writing, hearing, etc.
Part 2 – This employment applicant information is required to process a complete and accurate
criminal record check.
EMPLOYEE PERSONAL INFORMATION
First Name:
Middle Name:
Last Name:
Suffix:
OTHER NAME (S) USED (MAIDEN NAME, ALIAS)
First Name:
Middle Name:
Last Name: Suffix:
Date of Birth: Country of Citizenship:
Place of Birth (City, State/Province):
Height: Weight: Hair Color: Eye Color Gender: Female Male
Race: Asian Black Hispanic Native American Pacific Islander White All
Social Security Number:
ADDRESS
Street Address:
City: State: Zip Code: County:
Phone Number:
Job Title: Conditional Hire Date:
RESIDENCY
Driver’s License or State/Canadian ID Number:
State/Prov. License/ID Number
Has this employment applicant resided in Michigan continuously for the past 12 months? YES NO
PROFESSIONAL LICENSE(S) /CERTIFICATION(S)
1. License/Certification Number:
2. License/Certification Number:
3. License/Certification Number:
Michigan Medicine
Background Check
Consent & Disclosure
Part 2 - Consent
As a condition of being considered for a new or continued position at the University of
Michigan Health
System ("UMHS") as an employee, volunteer, or contractor:
1.
I hereby consent to and authorize MICHIGAN MEDICINE or its agents or contractors to
conduct background checks as
described above, including:
+
Verification of information submitted to UMHS, e.g., in applications or on this form
+
Searches of state and federal abuse and neglect registries and databases
+
Searches of state and federal criminal history records that,
depending on my job
classification, may include fingerprint-based checks
I understand that this consent extends to the release and sharing of such
information with the Michigan Departments of Community Health, Human
Services, Corrections, and State Police.
2.
I hereby authorize the release of any relevant information to MICHIGAN MEDICINE
or its agents or contractors to be
used to conduct the background check as required
under MICHIGAN MEDICINE policy and/ or Michigan Public Acts
27, 28 and 29 of 2006
or other applicable law.
3.
I understand that MICHIGAN MEDICINE will make the final employment, volunteer,
or contracting determination subject to the requirements of applicable law. I also
understand that MICHIGAN MEDICINE may terminate the
background check or
determine not to hire or retain at any stage of the process.
4.
I understand that federal and state laws such as the federal Fair Credit Reporting
Act (FCRA) may
provide me with certain rights regarding the accuracy, fairness, and
privacy of information collected
and used through the MICHIGAN MEDICINE
background check program. I understand that information about
5.
I understand that UMHS, in denying employment or other position to an applicant,
and reasonably
relying on information obtained through a background check, is
provided immunity from any action
brought by an applicant due to the decision. I
hereby further release the University and any of its
agents and contractors from
any other liability that may be incurred in connection with their review
and use of
information about me collected through the background check program, except in
cases of
gross negligence or intentional misconduct.
Signature of Applicant/Employee/ Volunteer/ Contractor Date
Michigan Medicine
Background Check
Consent & Disclosure
Part 3 - Disclosures
1. I certify that, if I am subject to the requirements of PA 27, 28, or 29 of 2006, I have not
been convicted
of a crime or offense that prohibits my employment, hire, or granting
of clinical privileges in a long-
term care setting as required by PA 27, 28 and 29
of 2006, within the applicable time period
prescribed by each crime. I can find out
whether I am subject to PA 27, 28, or 29 of 2006 by
contacting: (734) 647-5538.
A current list of the relevant crimes and offenses is available in the "Legal
Guide"
posted at: http:/
/
www.miltcpartnership.org/ I understand that conviction of one
of the listed crimes is good cause for termination of employment, contract, or status.
Signature of Applicant/Employee/ Volunteer/ Contractor Date
2.
I certify that (choose one option below):
o
I have never been convicted, pled guilty, or pied nolo contendere to
any crime. No
substantiated finding of patient or resident neglect,
abuse, or misappropriation of property has ever been made against
me by a federal or state agency, an employer, or any other
agency
or entity. I have never been sanctioned for federal health care
program or federal
contractor fraud, abuse, or misconduct. I have
never pled "not guilty by reason of insanity"
or an equivalent defense
and I have never been subject to an order or disposition of "not
guilty by reason of insanity" or equivalent order or disposition for any
crime.
(If checked, please skip question 3)
o
The list below in question 3 of my convictions, guilty pleas, nolo
contendere pleas; substantiated findings against me of patient or
resident neglect, abuse, or misappropriation of property;
sanctions
for federal health care program and federal contractor fraud, abuse
and
misconduct; and "not guilty by reason of insanity" pleas, orders,
or dispositions is true,
correct, and complete to the best of my
knowledge.
Signature of Applicant/Employee/ Volunteer/ Contractor Date
Michigan Medicine
Background Check
Consent & Disclosure
3.
I disclose, by listing below:
o
All offenses for which I have been convicted, pled guilty, or pled nolo
contendere, including all terms and conditions of sentencing, parole and
probation.
o
Any substantiated finding (whether by a court, an employer, or otherwise)
of patient or resident neglect, abuse, or misappropriation of property.
o
Any instance of federal health care program or federal contractor fraud,
abuse, or misconduct for which sanctions have been imposed.
o
Any instance when I pied "not guilty by reason of insanity" and any
instance in which I was subject to an order or disposition of "not guilty by
reason of insanity" for any crime
.
Signature of Applicant/ Employee/ Volunteer/Contractor Date
Offense
Date and Type
of Conviction/
Plea/Dispositio
n
Location
City/State)
r
.
Sentence/Sanction
Date of
Discharge
Michigan Medicine
Background Check
Consent & Disclosure
Part 4 - Conditional Employment
If
the University of Michigan Health System decides to employ or retain
me, or grant me clinical
privileges pending the results of the background
checks described above., on page
l,
I understand the following:
1.
Inaccurate or incomplete disclosures are good cause for termination of
employment, contract, and/ or
clinical privileges. If the background check
does not confirm my disclosure statements made above,
my
employment, contract, and/ or clinical privileges may be terminated,
unless l successfully prove that the disqualifying information is
inaccurate. I may also be subject to criminal sanctions.
2.
As a condition of my continued employment or work at MICHIGAN
MEDICINE or continued medical staff
membership and clinical privileges,
I will report in writing to the University of Michigan Health System
Compliance Office and my supervisor (or, in the case of a faculty
member, my Department
Chair) immediately if:
o
Any information provided in Part 3 above changes; or
o
I
am
arraigned
for any crime described
in the "Legal
Guide"
available
at
http:/
/
www.miltcpartnership.org/
or
o
I am notified of any government investigation of me in
connection federal health care programs or federal contracts
.
understand that reporting such an event is not necessarily cause for
termination or denial of
employment or privileges; but failure to make
a timely report may result in disciplinary action
against me up to and
including dismissal (and/ or, as applicable suspension or revocation of
clinical
privileges).
Signature of Applicant/ Employee/ Volunteer/ Contractor Date
Michigan Medicine
Background Check
Consent & Disclosure
Part 5 - Applicant Rights
1. I understand that at my request, MICHIGAN MEDICINE will provide a copy
of any disqualifying record information found on any of the relevant
registries or databases.
2.
I understand that if I believe the results of any disqualifying record
information found on any
relevant registry or database is inaccurate, it is
my responsibility to correct the record information by
directly contacting
the appropriate registry/ database owner.
3.
I understand that if I believe the results of the criminal history fingerprint
record are inaccurate, or if
a conviction contained in the criminal history
record is one that may be expunged or set aside, I may file an appeal of
any statutory work disqualification to the appropriate state licensing or
regulatory department.
Signature of Applicant/ Employee/ Volunteer/Contractor Date
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response
Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
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 www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
C 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.
C You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “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:
C a person has taken adverse action against you because of information in your credit
report;
C you are the victim of identify theft and place a fraud alert in your file;
C your file contains inaccurate information as a result of fraud;
C you are on public assistance;
C you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12
months upon request from each nationwide credit bureau and from nationwide specialty
consumer reporting agencies. See www.ftc.gov/credit for additional information.
C 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 lender.
C 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 www.ftc.gov/credit
for an explanation of dispute procedures.
C 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 reporting agency may
continue to report information it has verified as accurate.
C Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than
seven years old, or bankruptcies that are more than 10 years old.
C 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.
C 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 www.ftc.gov/credit.
C 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 (1-888-567-8688).
C 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.
C Identity theft victims and active duty military personnel have additional rights. For more
information, visit www.ftc.gov/credit.
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. Federal enforcers
are:
TYPE OF BUSINESS: CONTACT:
Consumer reporting agencies, creditors and others not listed below Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word
"National" or initials "N.A." appear in or after bank's name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks,
and federal branches/agencies of foreign banks)
Federal Reserve Consumer Help (FRCH)
P O Box 1200
Minneapolis, MN 55480
Telephone: 888-851-1920
Website Address: www.federalreserveconsumerhelp.gov
Email Address: [email protected]
Savings associations and federally chartered savings banks (word
"Federal" or initials "F.S.B." appear in federal institution's name)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in
institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal Reserve
System
Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil
Aeronautics Board or Interstate Commerce Commission
Department of Transportation , Office of Financial Management
Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture
