CRIMINAL HISTORY SEARCH CONSENT FORM
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, have had no prior convictions of an offense described in the Health And Safety Code which would bar or potentially bar employment as listed below.
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CRIMINAL HOMICIDE
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INDECENCY WITH A CHILD
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SOLICITATION OF A CHILD
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ARSON
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AGGRAVATED ROBBERY
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BURGLARY & CRIMINAL TRESPASS
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WEAPONS
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PUBLIC LEWDNESS
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PUBLIC INDECENCY
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KIDNAPPING & FALSE IMPRISONMENT
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AGREEMENT TO ABDUCT FROM CUSTODY
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SALE OR PURCHASE OF A CHILD
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ROBBERY
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ASSAULTIVE OFFENSES
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THEFT
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FRAUD
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INDECENT EXPOSURE
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A FELONY VIOLATION OF A STATURE INTENDED TO CONTROL THE POSSESSION OR DISTRIBUTION OF A SUBSTANCE
(INDIANA CONTROLLED SUBSTANCE ACT)
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I UNDERSTAND THAT THE HOME HEALTH AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT. I, THE UNDERSIGNED, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.
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