Prototype- Utah Employee Background Check Authorization

Utah Employee Background Check Authorization

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Utah Employee Background Check Authorization

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Employee Legal Name*

First NameMiddle NameLast Name
Employee Email*
example@example.com
Employer Legal Name*

First NameLast Name
Employer Email*
example@example.com
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
I understand that my personal information including name, date of birth, social security number and fingerprints will be used for the purpose of conducting a criminal history records search through any applicable state and federal databases. This information will be used by the Department of Human Services, Office of Licensing to determine my eligibility to have direct access to a child or vulnerable adult. My personal information and fingerprints may be retained for ongoing monitoring and comparison against future submissions to the state, regional or federal database and latent fingerprint inquiries. 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. I understand that I may request to review any results of this inquiry and understand that UCA 53-10-108 does not allow the Department of Human Services, Office of Licensing to provide a copy of those results to me. Before a determination is made, I understand that I will be afforded a reasonable amount of time to challenge the completeness and accuracy of the record through the procedures established by the Department of Human Services, Office of Licensing as well as contacting the Utah Bureau of Criminal Identification (Utah Criminal History Results), the State Identification Bureau (SIB) associated with any results that are outside of Utah, or the Federal Bureau of Investigation (Nationwide Criminal History Response Information). I have read the attached Privacy Statement and understand my rights according to this statement.

By signing this form, the applicant authorizes Morning Sun Financial Services, the State of Utah Department of Human Services, Office of Licensing as well as the Utah Bureau of Criminal Identification to release information to the self-directed program with the State of Utah and my prospective employer as it pertains to my potential employment. The applicant understands that employment is dependent on an approved background check. Also, by signing this form, I certify the information I provided on this form is true and correct and I acknowledge it is unlawful to provide false or misleading information concerning criminal history or security check to an employer. I agree that this Authorization form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any reports that may be requested.

The information obtained herein will only be used for the purposes of obtaining the background study required by DHS.
Employee Legal Name*

Legal First NameLegal Last Name
Employee Signature*

Clear
Date of Signature*

MonthDayYear
Date
Employees are eligible for immediate employment after submitting the Criminal Background Screening Application for up to30 days from their date of hire provided they work under the direct supervision of their Employer. If an employee has not received official approval from the Utah State Dept. of Licensing at the end of 30 days, the employee is no longer eligible for payment. If your employee provides any services after that date, DSPD funding will no longer be available to pay for their hours.

According to Utah Code 62A-2-120 (5) a “directly supervised” means that the person being supervised is under the uninterrupted visual and auditory surveillance of the person doing the supervising.

I understand and acknowledge receipt of this information and agree to directly supervise my employee for up to 30 days following date of hire or until an official approval or denial has been received by the Utah State Dept. of Licensing. I understand that if at the end of 30 days, if my employee has not received criminal background screening approval, funding will no longer be available.
Employer Legal Name*

First NameLast Name
Employer Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Utah Employee Background Check Authorization

Utah Employee Background Check Authorization

Signatures