Name: ________________________________________________________
Last First Middle (spell out)
Social Security Number: __________________________________________
Contact Phone: ___________________ Home Phone: __________________
email: ________________________________________________________
Maiden Name: ____________________ Aliases: _______________________
Marital Status: Single Married Divorced
______ Race ______ Eyes ______ Height Physically Disabled:
______ Sex ______ Hair ______ Weight Yes No
Identifying Scars/marks/tattoos (type & location):
_____________________________________________________________
Home Address:
________________________________________________
Number Street City/Town State Zip
Date of Birth: __________________________________________________
MM/DD/YYYY
Place of Birth: _________________________________________________
City and State or Country
Citizenship: ________________________ Visa Status: _________________
Drivers License Yes No
State:
___________ Licence #: ____________________________________
List the states that you have lived in the past:
_____________________________________________________________
Are you related to, or an unmarried partner of, an employee at the UConn Health Center? ___YES ___NO
If “YES list below. Continue on the reverse side if necessary. Per UConn Policy on Employment and Contracting for Service of Relatives, a relative is a spouse, child, step-child, child’s
spouse, parent, brother, sister, brother-in-law, sister-in-law, dependent relative or a relative domiciled in the employee’s household.
Name Relationship Department
Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently pending against you?
Exclude minor trafc violations, or any offense settled in juvenile court or under a youth offender law. ___YES ___NO
If “YES” list all cases below, providing details as indicated. Continue on the reverse side if necessary. Special Note: Under the provisions of (C.G.S. § 46a-80 a person is not disqualied from state employment
solely because of a prior conviction of a crime. The state can deny employment if a person is found unsuitable after considering (1) the nature of the crime, (2) information relating to the degree of rehabilitation,
and (3) the time elapsed sine the conviction. You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General
Statutes §46b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records that may
be erased are records pertaining to a nding of delinquency or that a child was a member of a family with service needs (C.G.S. § 46b-146), an adjudication as a youthful oender (C.G.S. § 54-76o), a criminal
charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon (C.G.S. § 54-142a).
Date Place Court Location Oense(s) Disposition
Have you ever been excluded, disbarred, restricted, disqualied, or sanctioned from any Federal or State programs or government
organizations? ___YES ___NO If “YES” list all cases below, providing details as indicated. Continue on the reverse side if necessary.
Date Place Agency Funding Current Status
Have there ever been any actions against your professional license(s)? ___YES ___NO ___N/A
If “YES” list all cases below, providing details as indicated. Continue on the reverse side if necessary.
Date Place Agency Funding Current Status
Have you brought or will you be bringing, or having transported, to UConn Health any chemicals, radioactive materials and/or any biological
materials that are pathogenic, viruses, bacteria, biological toxins, fungi, rickettsia, mycoplasma or parasitic organisms? ___YES ___NO
If “YES”, IMPORTANT REQUIREMENT: You must contact Environmental Health & Safety 860-679-2723 or jacobs@uchc.edu upon arrival.
I certify that the information provided by me on the Background Information Sheet is COMPLETE and TRUE to the best of my knowledge
and is made in good faith. I understand that if I knowingly make any misstatement of facts or fail to provide required information I am sub-
ject to disqualication or dismissal and other penalties as they may be prescribed by law, policy, or regulation.
SIGNATURE: ___________________________________________________________________ DATE SIGNED: ____________________________________
BACKGROUND INFORMATION SHEET
COMPLETE ALL SECTIONS AND SIGN AT THE BOTTOM
The information being solicited on this form is for conducting pre-employment criminal and/or other background
checks only and is not used in employment decisions unrelated to the results of the background check.
PUBLIC SAFETY USE
Result/Date
___ Cleared
___ Rejected - failure to disclose ____/____/____
___ Rejected - criminal history ____/____/____
___ Administrative Review Pending ____/____/____
___ Administrative Review Complete ____/____/____
UNPAID EXPERIENCES USE
Host Name:
Host Department:
Begin Date: End Date:
Vendor Contractor
Regular Student
HUMAN RESOURCES USE
Submitted by/return to:
Alexander D
Duggal J
Leone M
Logan M
Coco
Das
Dorenburg
Area:
McNamara E
Rucker P
Smith J
Clinical Ops
Clinical Faculty
Day Care
Dental Clinics
IT
Non Clinical
Research
Employee Type:
Grad Assistant
Dental Resident/
Non-Surgical
Host must complete this section
Bartis L
Volunteer Type:
VOLUNTEER USE
OTHER USE
Company Name:
UConn Health Contact:
rev. 02/2020
Job Title:
