Step 1 of 8 12% Full Name:* First Middle Last Tell us a little about yourself and why you chose the Healthcare field as a profession.* Describe a time you had to deal with a difficult patient and how you handled that.* What is your strongest skill as a caregiver or nurse? Why?* How would you handle if a family member were unsatisfied with a patient’s care?* How well are you able to identify a decline in your patient and make sound decisions? Give an example.* What would you do if you are having transportation issues when getting to work?* Gender* Male Female Are you over 18 years of age? Yes No Race* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Primary Phone:*Alternate Phone:Email Address:* Social Security:* Birth Date* MM slash DD slash YYYY Marital Status* Single Married Divorced Emergency contact information*NamePhone NumberRelation Position:* RN LPN CNA PCA/SITTER DSP ADMIN Available Working Dates / Salary*Available Working DateDesired Wage/Salary Availability*(State the times you are available for work below. e.g. 9AM – 2PM, 7AM – 7PM): MonTueWedThurFriSatSun Have you ever worked for Faith Staffing Agency, Inc before?* Yes No Do you have a relative/friend who worked or works for Faith Medical Services?* Yes No Who? Check each home care duties/tasks that you are able to perform.* Personal care Transfers Housekeeping Incontinent care Ostomy care Positioning Errands Foley catheter care ROM exercises Oral care Quad/Paraplegia care Medication Reminders Meal preparation CPR Check all skilled services your are competent with* Wound care Wound VAC PICC line care INT Oxygen Nebulizer Enteral feeding Suctioning G-Tube Med management Lab draw Irrigations Trach care Central lines TPN Venipunctures NG tube feedings Ventilator Urinary Catheters Pediatric care IM injections Check each home care duties/tasks that you are able to perform.* ISP goal Tracking Health Tracking HRST tracking progress notes none Are you willing to travel?* Yes No Please list ALL counties/areas that you are willing to travel to for work:*Check all that apply:* No Pets No Smoke Can't flip over 50lbs Hoyer lift Trach Care Bowel Program Assist with Ambulation Assist with bedpan/urinal/commode Bathing: Complete/partial/shower Bed Making: occupied/unoccupied Bed rails: how to use them Charting/Checklists CPR Documentation: vital signs Elimination check & record Feed patient/assist with meals Foley catheter care & emptying Hand Hygiene Intake & output Infection control precautions Nail care Oral hygiene Ostomy care Positioning patients Range of Motion exercises Others None Specify Have you ever been convicted of a felony?* Yes No Some of our clients do not speak English. Do you speak, write or understand any foreign language(s)?* Yes No What languages?Can you work nights/overnight?* Yes No Do you have a vehicle?* Yes No Personal Information*NameDepartmentPositionMedical Conditions Check list* Epilepsy Diabetes Arthritis Amputated foot, leg, arm or hand Loos of sight: one of both eyes or partial loss of uncorrected vision loss more than 75% bilateraly Residual disease from poliomyelitis Cerebral Palsy Parkinson's Desease Cardiovascular disorders Multiple sclerosis Tuberculosis Mental retardation: provided the employee's intelligence quotient is such that he fails within the lowest 2% of the general population: provided, however that it shall not be necessary for the employer to know actual intelligence quotient of the population Psychoneurotic disability: following confinement for treatment in a recognized medical institution for a period in excess of six months Hemophilia Sicke cell anemia Ankylosis of major weight bearing joints Hyperinsulism Muscular dystrophy Chronic ostemyelitis Total occupational loss of hearing Compressed air sequoias Ruptured intervertebral disc Hip Replacement Any condition that has been rated by a doctor as 20% or more impairment to the foot, leg, arm, hand, or to the body as a whole Any other chronic medical conditions or pre-existing disease None Back conditions:* A) Back surgery B) Degenerative disc disease C) Multiple back strains D) Chronic E) Other None Neck conditions:* A) Neck surgery B) Degenerative disc disease C) Multiple neck strains D) Chronic neck pain E) Other None Knee conditions:* A) Left knee surgery B) Right knee surgery C) Other None For yes responses, indicate the natural cause of injury or illness and name also the name of the physician in remarksSignature to agree* DOCUMENTATION POLICYNURSES POLICY AND PROTOCOLS It must be legible All nurses’ notes are to be signed by the nurse with your full legal signature and nursing credentials. Sign those credentials, you earned them. Be proud of them..LPN/RN Documentation must be accurate, detailed objective, precise and timely. All nurses’ notes must be signed by the patient or family member. This is proof of the nurse care and presence. Note that it is not legal or ethical to sign a client’s or family member’s signature. It constitutes fraud and is a felony. All Initial assessment must be completely filled out. For initial assessment packages, the yellow copies are left in the folder with the client and the white copies are returned back to the office. Holding your paperwork for too long only delays your payment for such services rendered. Called client’s MD? Document call/time and why. Check all appropriate boxes on the visit notes. DO NOT use white outs, scribble, trace over to change errors during your documentation. Simply draw a line across and write the correct information. Submit visit/progress notes within 7-14 days from the date of visit. A supervisory visit has to be done on the dates given on the visit schedule. NO exceptions. If unable to perform visit, contact the office/supervisor immediately. This is a state rule. DOCTOR’S ORDERS Always work with the MD orders. NO EXCEPTIONS! If MD did not order it, don’t do it! Doctor (and Faith Medical) must be notified of changes in client’s status. You call the doctor and document the communication. Verbal orders are taken, written, signed off and communicated back to your supervisor at Faith Medical Services within 24hrs by the RN/LPN All orders from a physician must be brought to the office (or faxed, emailed) Call your supervisor with “ALL NEW ORDERS” MEDICATION ADMINISTRATION At each visit, nurses must review all of the patient’s medications, dose and frequencies. Often, the physician’s office will notify patients of changes but not the nurse or agency. Changes should be called into the office immediately so that the computer records can be changed. At each Start of Care, the RN must review all medications and complete, date and sign the Medication Profile. It is important that you review the actual bottles for both prescription and over the counter medications and supplements to ensure that you have the correct spelling of the name, doses and frequencies. It is also important that you get the patient’s pharmacy name, address and telephone number to record on the form. It is a State regulation that we have the pharmacy name, address and telephone number. At each Follow-up and Resumption of Care, the RN must review the medication list, note changes on the on visit form. If there are no changes, the nurse should write “No changes”. CHECKLIST FOR COMPLETING PROPER STEPS IN THE ADMINISTRATION OF MEDICATIONS < Washes hands using proper technique. < Does not handle pills with bare hands. < Checks the medication 3 times during preparation. < Ensures they have identified the right client. < Explains the administration procedure(s) to the client. < Adheres to the 8 Rights of Medication Administration. < Observes the client take the medication or after the medication administration. < Documents the administration of each medication on the visit note. < Dispose supplies < Wash hands RIGHTS OF MEDICATION ADMINISTRATION Right patient Check the name on the order and the patient. Use 2 identifi ers. Ask patient to identify himself/herself. Right medication Check the medication label. Check the order. Right dose Check the order. Confi rm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose Right route Again, check the order and appropriateness of the route ordered. Confi rm that the patient can take or receive the medication by the ordered route. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confi rm when the last dose was given. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. Right reason Confirm the rationale for the ordered medication. What is the patient’s history? Why is he/she taking this medication? Right response Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. GENERAL PROCEDURES OF ADMINISTERING MEDICATIONS BY THE VARIOUS ROUTES PREPARATION: Compare the physician order with the medication provided by the pharmacy. Resolve any discrepancy in accordance with facility/agency policies before proceeding with the administration of the medication(s). Obtain the necessary supplies needed for the type of medication(s) to be administered such as medication cups, proper measuring devices, cotton balls, disposable gloves, tissues, crushing or splitting device, round nose tweezers. METRIC - decimal system of weights and measures using the gram, meter and liter. LIQUID: cubic centimeter (cc) = milliliter (ml) SOLID: 1 gram (gm) = 1000 milligrams (mg) HOUSEHOLD - system based on common, though not standard, measuring devices. tsp. = teaspoon Tbsp. = tablespoon = ounce 1 tsp. = 5 cc 3 tsp. = 1 Tbsp. = 15 cc 2 Tbsp. = 30 cc = 1 oz. START OF CARE/MISSED VISIT POLICY ALL START OF CARE per standard protocol is 24hrs except otherwise stated by the MD orders. Wound Vac standard protocol is 24-48 hrs depending on the last dressing change prior to discharge. When a client refuses services, do the following: Call the Office or the clinical supervisor Call and report to the client’s MD office Document the missed visit and the reason then fax or bring to the office within 24 hours. Follow up with the client next day and/or follow the agency’s instructions to you, whichever comes first. Report any problems back to the office All Nurses are required to inform the Office Staff before missing the visit in advance to allow us locate a suitable cover. However, if you have a missed visit because of a patient (e.g. patient was at the doctor’s appointment), you MUST notify the office immediately. A revisit schedule will be given to you by your supervisory, also communicate any rescheduling done by the patient.Employee Name First Last Date MM slash DD slash YYYY Signature to agree* Addendum to Company’s Equipment Use.I acknowledge that if I have been given any company equipment under my care and I am required to handle them with care. I agree to pay/replace in the given condition at the time of receipt of these equipments in the case of loss/theft, physical damage or any other damages that affect the functionality of the above equipment. I will sign for any equipment I receive.Employee Name First Last Date MM slash DD slash YYYY Signature to agree* Education Background, Training & Military ExperienceAll positions at Faith Medical Services requires a minimum educational level of a High School Diploma or equivalent.High School*High School NameCityStreetGraduation Date?College / University*College NameCityStreetGraduation Date?Other Institute: Employment History[List your last three (2) employers starting with the most recent]EMPLOYER:* List*PhoneCommencement DateDeparture DateReason for departure Supervisor Name and Phone Duties May we contact this employer? Yes No You selected no; please explain why? EMPLOYER: ListPhoneCommencement DateDeparture DateReason for departure Supervisor Name and Phone Duties May we contact this employer? Yes No You selected no; please explain why? EMPLOYER: ListPhoneCommencement DateDeparture DateReason for departure Supervisor Name and Phone Duties May we contact this employer? Yes No You selected no; please explain why? Does your employment history recorded above amount to 5 years or more?* Yes No You selected No; please explain the reason for a gap in employment below.I must meet the employability requirements of Federal Immigration Law and submit appropriate documentation to satisfy the requirements for completing INS Form I-9. If my application for employment is accepted, the effective date of my employment may in time I actually begin to work. If I accept the employment, I agree to comply with and be bound by the safety and health rules and regulations and rules of conduct of FAITH STAFFING AGENCY altogether with obligations set forth in the Company Policies. All information (including information on any accompanying resume) is correct and will be subject to verification.Signature to agree* References References List three persons not related to you who have knowledge of your work performance within the last three years.ReferencesClick the plus ( + ) sign on the right of the field below to add more references. We need up to 3.NamePhoneNo. of Years Acquainted Dear Applicant, We need the following for your application to be completed. Upload copies of the following: Upload your Resume Drop files here or Select files Max. file size: 32 MB. Upload your Security Card: Drop files here or Select files Max. file size: 32 MB. Upload your Driver's License Drop files here or Select files Max. file size: 32 MB. PPD (Tuberculosis Skin Test) or Chest X-ray (taken within a year) Drop files here or Select files Max. file size: 32 MB. Upload your CPR and First Aid Certification Cards Drop files here or Select files Max. file size: 32 MB. Upload your State of Georgia Nurse Aide Certification, RN\LPN Georgia License (or Tests) Drop files here or Select files Max. file size: 32 MB, Max. files: 3. Please click NEXT and wait patiently while your files are uploading. Once they are done uploading, you will be taken to the next page. Keep it up! You're doing awesome! ACKNOWLEDGEMENT OF APPLICANT’S NON-CRIMINAL JUSTICE PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL PRIVACY RIGHTS - TO BE COMPLETED BY INDIVIDUAL BEING FINGERPRINTED:APPLICANT TYPE* Owner (Facility) Applicant for Employment/Direct Access Employee (Facility) Non-Employee (Facility Volunteer) Contractor/Direct Access (Facility) Name* First Middle Last Date of Birth* MM slash DD slash YYYY Home Address Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email Telephone No.** Name of Agency Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands * I hereby authorize the Georgia Department of Community Health (DCH), Office of Inspector General, to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I understand a State and Federal fingerprint criminal background check will be conducted. By signing below, I am indicating that I have read and understand the terms and conditions of the attached Non-Criminal Justice Applicant’s Privacy Rights and Policy Act Statements. Signature to agree*CAREGIVER PORTAL - TO BE COMPLETED ONLY BY AN APPLICANT OR EMPLOYEE BEING FINGERPRINTED AS PART OF FACILITY LICENSURE. DOES NOT INCLUDE OWNERS OR FAMILY EMPLOYERS. APPLICANT TYPE* Applicant for Employment/Direct Access Employee (Licensed Facility) Non-Employee (Volunteer at Licensed Facility) Contractor/Direct Access Employee (Licensed Facility) The Georgia Caregiver Portal only contains the eligibility status of applicants and employees who have successfully passed the background screening process. The Caregiver Portal does not contain the names of applicants and employees who are ineligible. Family employers can access the Caregiver Portal to view a prospective applicant or current employee’s eligibility to determine their suitability for employment to provide personal care services to that employer’s elderly family member or wards. All services are performed at locations not licensed by DCH. Individuals should check one of the boxes below. I agree to the results of my background check determination being available to family employers in the Georgia Caregiver Portal. I am seeking employment only by licensed healthcare employers. I do not want or agree to the results of my background check determination being available to family employers. SignatureAs an applicant that is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/biometric-based criminal history record check for a non-criminal justice purpose (such as an application for a job or license, immigration or naturalization, security clearance, or adoption), you have certain rights which are discussed below: You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized. If your fingerprints/biometrics are used to conduct a FBI national criminal history check, you are provided a copy of the Privacy Act Statement that would normally appear on the FBI fingerprint card. If you have a criminal history record, the agency making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record. The agency must advise you of the procedures for changing, correcting, or updating your criminal history record as set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34. If you have a Georgia or FBI criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the agency denies you the job, license or other benefit based on information in the criminal history record. In the event an adverse employment or licensing decision is made, you must be informed of all information pertinent to that decision to include the contents of the record and the effect the record had upon the decision. Failure to provide all such information to the person subject to the adverse decision shall be a misdemeanor [O.C.G.A.§35-3-34(b) and §35-3- 35(b)]. You have the right to expect the agency receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of state and/or federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. If the employment/licensing agency policy permits, the agency may provide you with a copy of your Georgia or FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, information regarding how to obtain a copy of your Georgia, FBI or other state criminal history may be obtained at the GBI website (http://gbi.georgia.gov/obtaining-criminal-history-record-information). If you decide to challenge the accuracy or completeness of your Georgia or FBI criminal history record, you should send your challenge to the agency that contributed the questioned information. Alternatively, you may send your challenge directly to GCIC provided the disputed arrest occurred in Georgia. Instructions to dispute the accuracy of your criminal history can be obtained at the GBI website (http://gbi.georgia.gov/obtaining-criminal-history-record-information). Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non- governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. CAPTCHANameThis field is for validation purposes and should be left unchanged.
