Agency Emergency Hire Affidavit

Agency Emergency Hire Affidavit

I have not been convicted of any of the following penal code offenses, which may potentially bar employment

I acknowledge that if I am found to have been convicted of any other offenses, they may cause my employment to be terminated. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.













Due to the lack of sufficient personnel to adequately and safely care for our patients needs, we are hiring

He/She has consented to a criminal history check to be performed as part of our hiring process. During the sixty (60) days waiting period on the criminal history check, this document will serve as an acknowledgement that the above named person states that they have no conviction of an offense which would bar employment.

Offenses which would bar employment

Criminal homicide
Indecency with a child
Solicitation of a child
Arson
Kidnapping and false imprisonment
Agreement to abduct from custody
Sale or purchase of a child
Robbery

Offenses which potentially may bar employment

Assaultive offense
Theft
Fraud
Indecent exposure
Burglary and criminal trespass
Weapons
Public Lewdness
Public indecency

A felony violation of a statute intended to control the possession or distribution of a substance included in chapter 481, health and safety code (Indiana controlled substance act).

If we do not receive a response from the Indiana Department of Health within sixty (60) days, it is likely that no convictions were found. You would no longer be on an “emergency hire” status.

If however, a conviction is found, INDH will notify us as well as sending the same information to you. You will be given instructions as to what options you have available to you. INDH will send us a notice of determination as to weather you are employable. We will abide by this determination. All information concerning your criminal history will remain confidential.

I,consent to a criminal history check and further state that I have no conviction for any of the offenses listed above. I understand and agree to the terms of this agreement