WAIVER AGREEMENT
AND
FBI PRIVACY ACT STATEMENT
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
revised 5-4-18 bv
I hereby authorize (Name of Authorized Recipient) 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)
