Criminal History Search Form

* = Required Information

Name *

Date

I, , have had no prior convictions of an offense described in the Health and Safety Code which would bar or potentially bar employment as listed below.

CRIMINAL HOMICIDE
INDECENCY WITH A CHILD
SOLICITATION OF A CHILD
ARSON
AGGRAVATED ROBBERY
BURGLARY & CRIMINAL TRESPASS
WEAPONS
PUBLIC LEWDNESS
PUBLIC INDECENCY

KIDNAPPING & FALSE IMPRISONMENT
AGREEMENT TO ABDUCT FROM CUSTODY
SALE OR PURCHASE OF A CHILD
ROBBERY
ASSAULTIVE OFFENSES
THEFT
FRAUD
INDECENT EXPOSURE
A FELONY VIOLATION OF A STATURE INTENDED TO CONTROL THE POSSESSION OR DISTRIBUTION OF AN ILLEGAL SUBSTANCE)

* I UNDERSTAND THAT THE HOME HEALTH AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT. I, THE UNDERSIGNING, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRIMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.

Employee Name *

Supervisor Name *