THE UNIVERSITY OF TEXAS AT TYLER
College of Nursing and Health Sciences
CONSENT AND RELEASE
Required Background Check
A background check is required as part of the requirement when working in a clinical
setting. Some University-affiliated clinical facilities may also require disclosure of a
student’s background check report prior to permitting the student to participate in the
educational program at the facility. The UT Tyler Department of Health and Kinesiology
engages the services of a private agency to conduct this background check. A favorable
review of this information by the UT Department of Health and Kinesiology is not
binding upon a clinical facility. A clinical facility may refuse to permit a student to
participate in the clinical rotation / internship / practicum at the facility if background
check information is not provided, or if upon review of a student’s background check, it
determines the student is disqualified. Please complete the following information to
authorize the UT Tyler Department of Health and Kinesiology to obtain and review
background check reports.
________________________________________
Signature
________________________________________
Printed Name
________________________________________
Student Identification Number (required)
________________________________________
Date
Return form to:
Reuben Cowan, Lecturer
The University of Texas at Tyler
Department of Health and Kinesiology
3900 University Blvd.
Tyler, TX 75799
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