Fillable XtC5qA0x Litj OvL2- Disclosure Form Fillable

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XtC5qA0x Litj OvL2- Disclosure Form Fillable

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This form must be completed in full and signed annually.
, (collectively referred to as “school”) enters into affiliation agreements with
training sites to allow school students to obtain clinical experience necessary to complete their academic program. The
affiliation agreements between the training sites and school require the academic institution to obtain comprehensive
background checks for students/faculty who will provide direct services, or have unsupervised access to, or direct contact with
certain vulnerable populations as defined in the Washington State Child and Adult Abuse Information Law RCW 43.43.830-842.
Charge(s), conviction(s), and or/ criminal history information, including information regarding certain court and administrative
determinations, must be disclosed and verified before an applicant or student/faculty can be considered for placement at a
clinical site. A conviction/criminal history record does not necessarily disqualify an individual from placement at a clinical site.
However, certain criminal convictions and certain court administrative determinations may preclude assignment to a clinical site
and thus, completion of the program of study. Your clinical site will also require you to provide it with a satisfactory criminal
background check before you begin your clinical assignment or may require you to undergo a criminal background check of the
agency’s choice prior to beginning a clinical experience in that agency. Your assignment to a clinical training site will be
conditioned upon receipt of the disclosure form and report that is satisfaction to school and to the training site.
A. CRIMES AGAINST PERSONS, RELATING TO FINANCIAL EXPLOITATION
Have you ever been charged or convicted of any of the following crimes? (Include crimes that may have been renamed)
If yes, please check all that apply and provide detailed information in Section G
Abandonment of a child
Extortion (1st, 2nd, 3rd)
Promoting suicide attempt
Abandonment of a dependent person
Forgery
Prostitution
Abuse/Neglect of a child: RCW 26.44.020
Harassment
Rape (1st, 2nd, 3rd)
Arson
Homicide by abuse
Rape of a child (1st, 2nd, 3rd)
Assault (Custodial)
Homicide by watercraft
Reckless endangerment
Assault (1st, 2nd, 3rd, 4th Degree, Simple)
Identity theft
Robbery (1st, 2nd, 3rd)
Assault of a child (1st, 2nd, 3rd)
Incendiary devices
Selling erotic material to minor
Burglary (1st)
Incest
Sexual exploitation of a minor
Child buying or selling
Indecent exposure
Sexual misconduct with a minor
Child molestation (1st, 2nd, 3rd)
Indecent liberties
Stalking
Coercion
Kidnapping
Theft (1st, 2nd, 3rd)
Commercial sexual abuse of a minor
Luring
Unlawful imprisonment
Communication with a minor
Malicious explosion (1st, 2nd, 3rd)
Unlawful use of building for drug purposes
Criminal abandonment
Malicious harassment
Use of machine gun in felony
Criminal mistreatment
Malicious mischief
Vehicular assault
Controlled substance homicide
Manslaughter
Vehicular homicide
Custodial interference
Murder, aggravated
Voyeurism
Custodial sexual misconduct
Murder (1st, 2nd)
Violation of child abuse restraining order
Dealing in depictions of minor engaged in
sexual explicit misconduct
Patronizing juvenile prostitute
Violation of anti-harassment protection order
Domestic Violence
Promoting pornography
Drive by shooting
Promoting prostitution
School Logo!
(if needed)
B. RELATED PROCEEDINGS
(If yes, provide detailed information in Section G)
Have you ever been found in any judicial or administrative adjudicative proceeding to have committed: domestic violence,
abuse, sexual abuse, neglect, abandonment, violation of a professional licensing standard regarding a child or vulnerable adult,
or exploitation or financial exploitation of a child or vulnerable adult?
C. DRUG RELATED CRIMES
(If yes, provide detailed information in Section G)
Have you ever been charged or convicted of a crime related to the manufacture of, deliver, or possession with intent to
manufacture or deliver a controlled substance?
CRIMINAL HISTORY DISCLOSURE FORM
ACKNOWLEDGEMENT OF CONDITION OF CLINICAL ASSIGNMENT
1
D. MEDICARE/MEDICAID RELATED CRIMES
(If yes, provide detailed information in Section G)
Have you been debarred, excluded or otherwise ineligible for participation in federal health care programs?
YES
NO
Have you ever been convicted of any crime related to the delivery of services under Medicare/Medicaid or any state or federal
healthcare program, or convicted of any crime connected with the delivery of a healthcare item or service?
YES
NO
Have you ever been judged liable for civil monetary penalties for conduct related to the delivery of services, supplies, or other
participation in Medicare/Medicaid or any other state or federal healthcare program?
YES
NO
To your knowledge has your name ever appeared on the office of the inspector general’s list of excluded individuals?
YES
NO
Are you currently part of legal proceedings regarding possible exclusions?
YES
NO
E. HEALTH CARE LICENSURE
(If yes, provide detailed information in Section G)
Have you ever had your license as a health care practitioner revoked; and/or is there an action(s) listed on your health care
provider license?
YES
NO
F. OTHER CONVICTION OF CHARGES INFORMATION
(If yes, provide detailed information in Section G)
Excluding the crimes listed above, within the past 10 years have you ever been convicted of any other crime? Do not include
parking tickets/traffic citations. If yes, please indicate all conviction dates, incarceration release date(s) and the nature of the
offense(s). Attach additional page(s) if needed.
YES
NO
G. FOR ALL ITEMS MARKED YES IN ABOVE SECTIONS PLEASE GIVE SPECIFIC DETAILS INCLUDING:
•
The court of agency!
•
Convictions, charges, or action dates!
•
Sentences or penalties imposed!
•
Incarceration release dates!
•
Current standing (e.g. Parole, work release, suspended license, etc.) Please use separate page if necessary
ACKNOWLEDGEMENT STATEMENT
I understand that in connection with my clinical courses I will be subject to a criminal background check to be conducted
through _________________________________________ and Washington State Patrol. I understand that current, and/or a
record of conviction of, offenses as specified in RCW 43.43.830, RCW 43.43.834, RCW 43.43.842 or other state or federal
regulations may disqualify me from association with a training site and may affect my ability to complete the academic
program with school if I am a student. I understand that any false statement, omission, or misrepresentation may disqualify
me from association with a training site and/or may be grounds for dismissal from the school program or other discipline.!
UNDER PENALTY OF PERJURY, I certify that this information is true, correct, and complete to the best of my knowledge. I
understand that if I am accepted to the school program, I can be discharged for any misrepresentation or omission in the
above statement. I understand that I am obligated to notify the school program within 30 days, in writing, if I am charged or
convicted of any crime or if any court or administrative determinations are made against me during the application period
and/or while enrolled as a student/faculty and are subject to clinical training site approval. If the school program is unable to
place a student/faculty at a clinical site due to his/her conviction/criminal history record or background report based on
stricter regulations at the clinical training site, school is under no obligation to find another clinical site.!
Authorized for Repeat Background Checks and Dissemination of Results:
I agree to pay for and provide school with ongoing criminal background checks conducted according to school policy during
my time as a student. I authorize dissemination of my self-disclosure information, background check results, and conviction
records to clinical training sites as deemed necessary by the school program during my academic program. I understand
that school will provide the records listed above only with the condition that the receiving party or parties will be notified by
the school program that they may not disclose the information to other parties, in a personally-identifiable form, without my
further consent, unless the other parties are otherwise eligible under federal or state law to receive the records.
Academic Institution:
Academic Program:
Print Name:
Signature:
Date:
CRIMINAL HISTORY DISCLOSURE FORM
ACKNOWLEDGEMENT OF CONDITION OF CLINICAL ASSIGNMENT
2
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XtC5qA0x Litj OvL2- Disclosure Form Fillable

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Completed 10 November 2021

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