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WAIVER AGREEMENT
AND
FBI PRIVACY ACT STATEMENT
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
I hereby authorize the Kansas State Board of Healing Arts to submit a set of my fingerprints to the Kansas Bureau of
Investigation (KBI) for the purpose of identifying me and accessing and reviewing Kansas and/or national criminal history
records that may pertain to me. Pursuant to K.S.A. 22-4701 et seq. and K.S.A. 22-5001, the Authorized Recipient may
obtain my criminal history record information for noncriminal justice purposes. By signing this waiver, it is my intent to
authorize release to the above-referenced Authorized Recipient of any Kansas and/or national criminal history record that
may pertain to me. I further understand that, if applicable, the Authorized Recipient may choose to deny me unsupervised
access to children, the elderly, or individuals with disabilities until the criminal history background check is completed.
I understand that, upon my request, the Authorized Recipient will provide me a copy of the criminal history background
report, received on me, for the purpose to challenge the accuracy and completeness of any information contained in any such
report. I may be afforded a reasonable amount of time to correct or complete the criminal history record (or decline to do so)
before the Authorized Recipient makes a final decision about my status as an employee, volunteer or contractor, or my
eligibility for any pertinent license, certification or registration, or adoption. See 28 CFR 50.12(b).
I understand that officials receiving the results of the criminal history record check are to use those results only for authorized
purposes and are prohibited from retaining or disseminating such results in violation of federal statute, regulation or
executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.
(See 5 United States Code (USC) 552a(b); 28 USC 534(b); 42 USC 14616, Article IV(c); 28 CFR 20.21(c), 20.33(d), and
906.2(d).)
FBI PRIVACY ACT STATEMENT
Authority:
The FBI's acquisition, preservation, and exchange of information requested by this form is generally authorized under 28
U.S.C.534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes,
hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/or orders of the Attorney
General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L.
94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however,
failure to furnish the information may affect timely completion or approval of your application.
Social Security Account Number (SSAN).
Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the
Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is
mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it.
Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.
Principal Purpose:
Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint-based
checks. Your fingerprints and other information contained on (and along with) this form may be submitted to the requesting
agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the submitted
information to available records in order to identify other
information that may be pertinent to the application. During the processing of this application, and for as
long hereafter as may be relevant to the activity for which this application is being submitted, the FBI
may disclose any potentially pertinent information to the requesting agency and/or to the agency conducting the
investigation. The FBI may also retain the submitted information in the FBI's permanent collection of fingerprints and related
information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature
of your application, the requesting agency and/or the agency conducting the application investigation may also retain the
fingerprints and other submitted information for other authorized purposes of such agency(ies).
