Article Structure
The Illinois Waiver form serves as a crucial document for health care workers seeking employment within the state. It facilitates a fingerprint-based criminal background check, which is essential to determine an applicant's suitability for work in health care settings. The form requests comprehensive personal information, including the applicant's name, address, Social Security number, and employment history. It emphasizes the importance of accuracy and honesty in reporting any past criminal offenses or administrative findings related to abuse or neglect. Specific sections of the form inquire about previous certifications in other states and any rehabilitation programs completed following substance abuse-related offenses. This information is vital for the Illinois Department of Public Health as they assess an individual's eligibility to be included in the Health Care Worker Registry. Additionally, the waiver form requires consent for the release of criminal history records to ensure that potential employers are equipped with accurate and relevant information. Beyond verifying an applicant's background, the document underscores the commitment to protecting the health and safety of patients, making it a necessary step for anyone looking to enter or continue in the health care profession in Illinois.
Illinois Waiver Example
STATE OF ILLINOIS
Illinois Department of Public Health
HEALTH CARE WORKER WAIVER APPLICATION
Illinois Department of Public Health
Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761
Phone
All information requested on this application must be provided before you will be considered for a waiver. Type or print clearly in ink.
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Today’s Date |
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Name |
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(First, Full Middle and Last) |
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Address |
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(Street, Apartment #, P. O. Box) |
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(City, State, ZIP Code) |
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Maiden Name (or other name(s) used)
Telephone |
Social Security Number (required) |
I hereby authorize the Illinois Department of Public Health, the Department’s designee that trains or tests health care workers, a staffing agency, or the health care employer to request a
I understand that the information requested below regarding sex, race, height, eye color, and date of birth is for the sole purpose of identification, the gathering of the above mentioned information and the processing of this waiver application. This information will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.
Male
Female Race |
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Height |
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Eye Color |
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Date of Birth |
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AChinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander B Black or African American (Not Hispanic or Latino)
H Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) I American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states
of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition. U Of undetermined race or of untold mixture
W Caucasian (not Hispanic or Latino)
Work History – If you have previously been employed, you must provide an entire work history or attach a complete resume. Start with your current employer. Attach addition pages if necessary.
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Employer |
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Date Started |
Separation Date |
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Employer’s Address, City, State, ZIP Code |
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Employer |
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Date Started |
Separation Date |
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Employer’s Address, City, State, ZIP Code |
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Other states where you have lived or worked |
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If the use of alcohol or other drugs was involved in the offense, were you ordered to participate in a rehabilitation program as part of the
judgment? |
Yes |
No |
If yes, you must provide proof of successful completion of the rehabilitation program. |
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Were you required to pay a fine in connection to a disqualifying offense? |
Yes |
No |
If yes, you must provide |
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proof of having paid all fines unless you are on a payment schedule. If on a payment schedule, you must provide proof that you are
If you were released on probation (or mandatory supervised release) or parole, you must provide proof of having successfully completed it.
Have you been certified as a nurse aide/assistant in another state? |
Yes |
No |
If yes, you must attach a copy of |
your certification or verification information (such as your certification number__________________________________).
Name used when certified_____________________________________________. If your current name is different, please attach a copy
of the legal document(s) used to change your name (i.e. marriage certificate, divorce decree, etc.) and a copy of your driver’s license or other picture identification.
Have you ever had an administrative finding of abuse, neglect or theft?
Yes
No
If “yes,” indicate in what state this finding was issued.
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
Yes
No
If “yes,” provide the circumstance surrounding each offense (what happened, how many years have passed since the offense, the individuals involved, your age at the time of the offense, and any other circumstances surrounding the offense) as well as the state in which you were convicted. If you have been convicted in another state, you must provide information concerning those convictions or attach the complete results of a criminal history records check from that state. If you have a federal conviction, you must provide information concerning that conviction or attach the complete results of a criminal history records check from the Federal Bureau of Investigation. If more space is needed, please attach additional pages. Do not include convictions that have been expunged, sealed or were a juvenile adjudication.
A copy of the following items may be submitted with this application but are not required. (This material will not be returned to you)
1.A current or recent employment reference.
2.A character reference.
3.Other evidence demonstrating the ability of the applicant to perform the employment responsibilities competently and evidence that the applicant does not pose as a threat to the health or safety of residents, patients or clients.
I certify that the above is true and correct and give my consent for my name to appear on the Department’s Health Care Worker Registry with the results of my criminal history records check.
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As the parent or guardian of the above named individual, who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.
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Mail this completed form to Illinois Department of Public Health, Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761. The Department will send you a Livescan Request Form by return mail. You will use the Livescan Request Form to have your fingerprints collected from one of the contracted livescan vendors.
Form Characteristics
| Fact Name | Details |
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| Governing Law | Health Care Worker Background Check Act (225 ILCS 46) |
| Application Requirement | All requested information must be provided to be considered for a waiver. |
| Fingerprint Authorization | Applicants authorize a fingerprint-based criminal history records check by the Illinois State Police. |
| Liability Clause | Applicants agree not to hold state agencies liable for releasing criminal history information. |
| Identification Information | Data on sex, race, and other identifying factors is for identification purposes only. |
| Incomplete Applications | Submitting the form without required documents may delay the application process. |
Guidelines on Utilizing Illinois Waiver
Completing the Illinois Waiver form is an essential step in the process of obtaining a waiver. Ensure that all information is filled out accurately and thoroughly, as incomplete forms may delay your application. Follow the steps below to complete the form properly.
- Write today’s date in the designated field.
- Fill in your full name: first name, middle name (if applicable), and last name.
- Provide your complete address, including any apartment number, city, state, and ZIP code.
- Indicate your maiden name or any other names you have used previously.
- Write your telephone number in the specified area.
- Enter your Social Security number. Note that this is required by law.
- Select your gender by checking the appropriate box for either Male or Female.
- Indicate your race by selecting the appropriate letter from the options provided (A, B, H, I, U, W).
- Provide your height and eye color in the respective fields.
- Fill in your date of birth.
- List your entire work history, beginning with your current employer. Include employer names, dates of employment, and addresses.
- Indicate any other states where you have lived or worked.
- Answer the questions regarding any involvement with alcohol or drugs during the offense, including whether you participated in a rehabilitation program.
- If applicable, provide proof of successful completion of the rehabilitation program.
- Answer if any fines were associated with a disqualifying offense and provide proof of payment or payment schedule status.
- Indicate if you have been certified as a nurse aide/assistant in another state and provide the required details.
- Attach legal documents for any name changes if your current name differs from the certified name.
- Answer if you have ever had findings of abuse, neglect, or theft, and in which state this was issued.
- Disclose any criminal offenses you have been convicted of (excluding minor traffic violations) and provide detailed information about each conviction.
- If needed, attach additional pages for more space or submit criminal history records checks from other states or federal sources.
- Indicate if you want to submit optional, supplementary materials like employment and character references.
- Sign and date the form indicating that the information provided is accurate.
- If applicable, a parent or guardian must sign to consent for individuals under 17 years old.
- Mail the completed form to the Illinois Department of Public Health at the specified address.
After submission, expect to receive a Livescan Request Form from the Department by return mail. This will facilitate the collection of your fingerprints at a contracted vendor, a necessary next step in the waiver process.
What You Should Know About This Form
What is the purpose of the Illinois Waiver form?
The Illinois Waiver form is primarily used by health care workers who are applying for a waiver regarding background checks conducted by the Illinois Department of Public Health. This form collects essential personal information, including employment history and criminal background, to ensure the suitability of individuals for employment in health care settings. By completing this form, applicants help facilitate the processing of their waiver request and contribute to maintaining safety standards within the health care industry.
What information is required to complete the Illinois Waiver form?
The form requires various details, including your full name, address, Social Security number, and contact information. Additionally, it asks for your work history, any criminal offenses, and whether you have been certified as a nurse aide or assistant in another state. Specific questions about previous convictions, rehabilitation programs attended, and any related documentation will also be needed. Be sure to provide accurate and complete information, as this is crucial for your application to be considered.
How will my personal information be used?
The personal information you provide on the Illinois Waiver form is solely for identification purposes. It aids the Illinois Department of Public Health in reviewing your application and supporting the processing of your waiver request. Importantly, while some demographic information is collected, this data is not used to discriminate against you in accordance with the law. Your privacy and rights are respected throughout this process.
What should I do if I have prior convictions?
If you have past convictions, it is vital to disclose this information on the waiver form. You will be asked to provide details about each offense, such as the circumstances surrounding it, your age at the time, and the duration since the incident occurred. Supporting documentation, such as proof of rehabilitation or satisfactory completion of probation, must also be submitted to enhance your application. Honesty is critical here, as failure to disclose may lead to complications in employment eligibility.
How can I submit the completed Illinois Waiver form?
Once you have filled out the Illinois Waiver form completely, you should mail it to the Illinois Department of Public Health at the designated address listed on the form. This is the Health Care Worker Registry. After your submission is received, the Department will respond by sending a Livescan Request Form. Keep in mind that you will need this form to have your fingerprints taken, which is a crucial part of the background check process.
What happens after I submit the Waiver form?
After submitting your completed Illinois Waiver form, you will receive a Livescan Request Form by mail from the Illinois Department of Public Health. This form is essential for obtaining your fingerprint-based criminal history records check. It is important to follow the instructions provided with this form to ensure your fingerprints are collected properly and submitted in a timely manner, as this is part of the overall evaluation process and required for the waiver application to proceed.
What if I need assistance with the Illinois Waiver form?
If you encounter challenges while completing the Illinois Waiver form, or if you have specific questions, you may contact the Illinois Department of Public Health directly. They can provide guidance and clarity on any aspect of the form or the process in general. It is always best to seek help if unsure, as this will ensure that your application is completed accurately and efficiently.
Common mistakes
Filling out the Illinois Waiver form can seem straightforward, but many people make common mistakes that can delay the process. One significant error is failing to provide all required information. When an applicant leaves out essential details, such as their Social Security number or current address, it can lead to rejection or delays in processing. The form states clearly that complete information is necessary, so it is crucial to check each section before submission.
Another frequent mistake involves unclear handwriting. While the form allows applicants to type or print in ink, some still opt for handwriting and end up being difficult to read. If the information cannot be clearly understood, it may result in miscommunication or errors that could impact the application. To avoid this, applicants should take their time to write neatly or, when possible, type the information.
Missing deadlines can also be a common pitfall. Applicants should be aware of any associated timelines for submitting their waivers. If a form is turned in late, it can complicate employment opportunities or result in additional inquiries. Staying organized and setting reminders can help ensure timely submission.
Sometimes, applicants fail to include the necessary documentation. When prior offenses or certifications are involved, providing proof is mandatory. For example, if a rehabilitation program was completed after an offense, documentation must be attached. Without these documents, the application may be deemed incomplete, resulting in delays or rejections.
Another mistake people often make is neglecting to sign the form. Although it seems simple, forgetting to provide a signature can stall the entire process. Both the applicant's and, if applicable, the guardian's signatures are needed. A quick review for signatures before sending the form can help avoid this oversight.
Understanding the required information regarding race and other identifiers is also essential. Misinterpretations or mistakes here can affect the processing of the application. Ensure clarity in understanding the categories and providing accurate information to avoid incorrect assumptions.
Lastly, individuals sometimes provide outdated information regarding previous employment or certifications. The form requires current and accurate work history and certifications. Providing the wrong details can lead to further inquiries or complications in the verification process. Keeping records up-to-date can ease this task.
Documents used along the form
The Illinois Waiver form is an essential document for individuals seeking to request a waiver in relation to health care employment. Alongside this application, several other forms and documents are commonly required to ensure a thorough background check and verification process. Below is a list of these accompanying documents, each playing a significant role in the waiver application process.
- Livescan Request Form: This form is sent to applicants upon receipt of the waiver application. It is crucial for scheduling fingerprint collection at approved vendors, enabling background checks to be conducted.
- Criminal History Records Check: An applicant may need to submit results of a criminal history check from previous states of residence or from federal agencies. This document verifies an individual's criminal background, contributing to the evaluation of suitability for employment.
- Verification of Rehabilitation: If an applicant was required to participate in a substance abuse rehabilitation program, proof of successful completion is necessary. This document demonstrates the individual’s commitment to recovery and compliance with legal judgments.
- Name Change Documentation: If the applicant has changed their name (e.g., through marriage or divorce), they must provide legal documentation, such as a marriage certificate or divorce decree, to clarify any discrepancies in records.
- Employment References: A current or recent employment reference letter may enhance an applicant's profile. This document holds value in showcasing the individual’s work ethic and history, as perceived by previous employers.
- Character References: Letters of recommendation from personal acquaintances can support an applicant's case. They provide insights into the individual’s character and reliability, particularly in a health care environment.
- Proof of Certifications: For those who have been certified as nurse aides or assistants in other states, attaching copies of these certifications or verification of such credentials is important. This documentation confirms the applicant’s qualifications in the health care field.
- Proof of Fine Payments: If an applicant was ordered to pay fines due to disqualifying offenses, they must provide evidence of payment. This could include receipts or other documentation proving compliance.
- Work History: A complete work history is essential for the application process, detailing all previous employers. This information helps establish experience and verifies the applicant’s professional journey.
In conclusion, these additional documents collectively support the Illinois Waiver application. Each one plays a significant role in providing a comprehensive view of the applicant's background, qualifications, and overall suitability for employment in health care settings. It is crucial for applicants to ensure that they gather and submit all relevant documents alongside their waiver application to facilitate a smooth approval process.
Similar forms
- Background Check Consent Form: Similar to the Illinois Waiver, this form requires individuals to authorize the release of their criminal history for employment purposes, making sure they meet the necessary legal requirements for the job.
- Employment Application: Much like the Illinois Waiver, an employment application gathers personal information, work history, and references, aiming to evaluate an individual’s suitability for a specific position.
- Medical Release Form: This form, similar to the Illinois Waiver, allows health care organizations to obtain medical history and records, often to ensure that prospective employees are fit for work.
- Volunteer Application: Similar in structure, a volunteer application includes personal information and background checks to determine an individual’s eligibility for volunteer positions, especially in sensitive settings.
- Employee Onboarding Form: This form collects similar information as the Illinois Waiver, including identification details, work history, and consent for background checks as part of the onboarding process.
- Child Care Background Check Form: This document also aims to evaluate criminal records of individuals working with vulnerable populations, seeking to ensure safety similar to the goals of the Illinois Waiver.
- Professional Licensing Application: Like the Illinois Waiver, this application is often used in fields requiring licensing and includes a review of any criminal history to determine eligibility for licensure.
- Patient Confidentiality Agreement: While primarily focused on confidentiality, this document requires participants to agree to background checks, ensuring trust and safety similar to the waiver’s intent.
- Fitness for Duty Form: This form evaluates an individual's readiness to perform job duties, requiring disclosure of any relevant history, akin to the Illinois Waiver's information-gathering approach.
- Drug Screening Consent Form: Similar to the Illinois Waiver, this consent form is often required by employers to ensure a drug-free workplace by allowing for testing and background checks.
Dos and Don'ts
When filling out the Illinois Waiver form, consider the following guidelines to ensure a smooth application process:
- Complete All Fields: Provide all requested information on the form. Omitting details may delay processing.
- Use Clear Writing: Type or print clearly in ink to avoid misinterpretation of your entries.
- Check Your Answers: Review your responses for accuracy, especially names and dates, before submitting.
- Include Required Documents: Attach any supporting documents, such as proof of rehabilitation or employment history, as necessary.
Additionally, avoid these common mistakes:
- Do Not Skip Sections: Leaving any parts of the form blank can result in processing delays.
- Avoid Illegible Writing: Illegible handwriting may lead to confusion and errors in your application.
- Do Not Include Expunged Convictions: Only provide information on convictions that have not been resolved or sealed.
- Do Not Forget to Sign: Ensure you sign and date the application, as missing signatures will result in rejection.
Misconceptions
Understanding the Illinois Waiver form can be tricky, and there are several misconceptions that often arise. Here are seven common misunderstandings and clarifications:
- Misconception 1: The waiver can be submitted without complete information.
- Misconception 2: A criminal record automatically disqualifies an applicant.
- Misconception 3: Providing my Social Security number is optional.
- Misconception 4: My information will be used for discrimination purposes.
- Misconception 5: Submitting documents is optional for proving my background.
- Misconception 6: My application will be processed without additional steps.
- Misconception 7: If my waiver is denied, I cannot reapply.
This is not true. All information requested on the application must be provided. Incomplete applications could delay the processing of your waiver.
Not necessarily. While a criminal record can impact your eligibility, it does not automatically disqualify you. The Department reviews each case individually to assess suitability for employment.
This misconception is incorrect. The provision of your Social Security number is required by law. It helps in verifying your identity and conducting background checks.
This is false. The application states that the personal information requested is solely for identification purposes and cannot be used for discrimination.
This is misleading. While some items may be submitted as supporting documents, providing proof of rehabilitation or completed fines is necessary if applicable to your case.
This is not accurate. After submitting the form, you will need to complete a Livescan fingerprinting process, which is required for a thorough background check.
This is false. If a waiver is denied, you may appeal the decision and potentially reapply in the future. Understanding why it was denied will be helpful for any subsequent applications.
Key takeaways
Filling out the Illinois Waiver form can feel overwhelming, but understanding the process can make it much easier. Here are some key takeaways to keep in mind:
- Complete All Sections: It is crucial to provide all requested information. Missing details can delay the processing of your waiver.
- Clear and Legible: Ensure that your answers are typed or printed clearly in ink. This helps avoid any misunderstandings or errors.
- Remember Your Authorizations: When signing the form, you authorize several agencies to access your criminal history, which is necessary for your application.
- Provide Accurate Work History: Include a complete history of your employment or attach a detailed resume. Accurate information helps establish your work credentials.
- Disclosures Are Key: If you've had any disqualifying convictions, disclose this information honestly. Transparency is invaluable in this process.
- Proof of Rehabilitation: If your past convictions involved drugs or alcohol, and you completed a rehabilitation program, attach proof of this successful completion.
- Documentation for Changes: If your name differs from what appears on any certification or record, attach legal documents that validate your name change.
- Character References Help: Consider submitting character or employment references along with your application. While optional, they can bolster your case.
- Mailing Instructions Matter: After completing the form, mail it to the specified address to ensure it reaches the Department of Public Health properly.
By following these guidelines, applicants can navigate the waiver process more effectively and increase their chances of a favorable outcome.
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