11/22/11
ACKNOWLEDGEMENT OF CRIMINAL BACKGROUND CHECK REQUIREMENTS APPLICABLE TO
STUDENTS SEEKING ADMISSION TO ALLIED HEALTH OR NURSING PROGRAMS ON OR AFTER SEPTEMBER 1, 2011
Maricopa County Community College District
In applying for admission to a Nursing or Allied Health program (“Program”) at the Maricopa County Community College District , you
are required to disclose on the Arizona Department of Public Safety (DPS) form all required information and on the MCCCD authorized
background check vendor data collection form any arrests, convictions, or charges (even if the arrest, conviction or charge has been
dismissed or expunged), or participation in first offender, deferred adjudication, pretrial diversion or other probation program on this
form. Additionally, you must disclose anything that is likely to be discovered in the MCCCD supplemental background check that will
be conducted on you.
Please complete the DPS form, the MCCCD authorized background check vendor form and any clinical agency background check form
honestly and completely. This means that your answers must be truthful, accurate, and complete. If you know of certain information
yet are unsure of whether to disclose it, you must disclose the information, including any arrest or criminal charge. Additionally,
By signing this acknowledgement, you acknowledge the following:
1. I understand that I must submit to and pay any costs required to obtain a Level-One Fingerprint Clearance Card and an MCCCD
supplemental criminal background check.
2. I understand that failure to obtain a Level-One Fingerprint Clearance Card will result in a denial of admission to a Program or
removal from it if I have been conditionally admitted.
3. I understand that I must submit to and pay any costs required to obtain an MCCCD supplemental background check.
4. I understand that failure to obtain a “pass” as a result of the MCCCD supplemental criminal background check will result in a
denial of admission to a Program or removal from it if I have been conditionally admitted.
5. I understand that, if my Level-One Fingerprint Clearance Card is revoked or suspended at any time during the admission
process or my enrollment in a Program, I am responsible to notify the Program Director immediately and that I will be
removed from the Program.
6. I understand that a clinical agency may require an additional criminal background check to screen for barrier offenses other
than those required by MCCCD, as well as a drug screening. I understand that I am required to pay for any and all criminal
background checks and drug screens required by a clinical agency to which I am assigned.
7. I understand that the both the MCCCD supplemental or the clinical agency background check may include but are not limited
to the following:
• Nationwide Federal Healthcare Fraud and Abuse Databases
• Social Security Verification
• Residency History
• Arizona Statewide Criminal Records
• Nationwide Criminal Database
• Nationwide Sexual Offender Registry
• Homeland Security Search
8. By virtue of the MCCCD supplemental background check, I understand that I will be disqualified for admission or continued
enrollment in a Program based on my criminal offenses, the inability to verify my Social Security number, or my being listed
in an exclusionary database of a Federal Agency. The criminal offenses for disqualification may include but are not limited to
any or all of the following:
Social Security Search-Social Security number does not belong to applicant
Any inclusion on any registered sex offender database
Any inclusion on any of the Federal exclusion lists or Homeland Security watch list
Any conviction of Felony no matter what the age of the conviction
Any warrant any state
Any misdemeanor conviction for the following-No matter age of crime
o violent crimes
o sex crime of any kind including non consensual sexual crimes and sexual assault
o murder, attempted murder
o abduction
o assault
