West Virginia Personal Options Criminal Background Check Instructions

Transcription

1 Public Partnerships, LLC E Brockway Ave, Suite E Morgantown, WV Phone: Fax: West Virginia Personal Options Criminal Background Check Instructions You are required to submit and pass a State and Federal Criminal Background Check (CBC) prior to providing Medicaid home and community-based services for payment. In addition, you will be required to complete a CBC every five years for the duration of your employment. The cost of all CBCs is your responsibility. You must provide Public Partnerships, LLC (PPL) with adequate payments for the cost of completing the CBC prior to your appointment (MONEY ORDER OR CERTIFIED CHECK only). It is very important that you keep your appointment because you will not be able to work until we receive an eligible status from WV CARES. Your results will be retained by the State Police and FBI to allow for updates of any criminal history or changes in regulations. PPL will receive monthly updates regarding your CBC. If the result of the initial or ongoing CBC reveals negative findings, WV CARES will place you on a list of employees prohibited from continued employment. Public Partnerships, LLC, will schedule the initial appointment on your behalf through WV CARES. Please fill out the Scheduling Form included in your CBC packet. You will not be able to work until PPL receives notification of your eligibility and all additional requirements have been completed and passed. Employees shall not be approved for employment if convicted of the following crimes: State or Federal health and social services program-related crimes Patient abuse or neglect Health care fraud Felony drug crimes Crimes against care-dependent or vulnerable individuals Felony crimes against the person Felony crimes against property Sexual offenses Crimes against chastity, morality and decency Crimes against justice Revised 9/25/2017

2 How to Complete and Submit Your Criminal Background Check Application A. Complete the Application Packet: 1. Complete the Criminal Background Check Scheduling Form 2. Complete the Disclosure Application and Consent Form 3. Complete the Request for Variance of Fitness Determination Form ONLY If you are aware of a conviction that may disqualify you from working, this form will need to be completed. WV Cares will review the reason for failure and determine if the failure can be waived. Some of the reasons that may allow employment would be passage of time since conviction, demonstration of rehabilitation, or relevancy of conviction with respect to employment. If you receive a not eligible determination, this form can then be completed and submitted to WV CARES within 30 days of the notification. WV CARES will have 60 days to review the Variance form and make a determination. B. Obtain 2 MONEY ORDERS or CERTIFIED CHECKS to pay for the fees: Please note that these 2 fees are separate and need to be submitted as 2 separate checks. $34.25 made payable to Morphotrust and $20 made payable to WV Cares C. Return completed forms and PAYMENTS to PPL Morgantown office: Mail the completed application and payments to PPL Morgantown office at: Public Partnerships, LLC Dean Small: CBC Processing E Brockway Ave, Suite E Morgantown WV, D. Once all forms and payment have been received and processed by PPL, your fingerprint appointment will be scheduled. PPL will notify you of the appointment by phone, mail or , depending on how you chose to be notified. E. Please be sure to keep your fingerprint appointment. If you miss your appointment, please contact Morphotrust at to reschedule. If your application is not completed correctly or payments are not received, your fingerprint appointment can NOT be scheduled and services can NOT be billed. Revised 9/25/2017

3 Public Partnerships, LLC E Brockway Ave, Suite E Morgantown, WV Phone: Fax: West Virginia Personal Options Criminal Background Check (CBC) Scheduling Form ADW IDD TBI Public Partnerships will schedule the initial appointment on your behalf through WV CARES. Please fill out the form below. You will not be able to work until PPL receives your fitness determination notification. Applicant/Employee Name: Participant Name: Has the applicant completed a CBC through WV CARES within the last five years? Yes No Resource Consultant Name: What Date and Time are you available for your fingerprint appointment? Please list more than 1 option: How do you want to be notified of your fingerprint appointment? Phone: Mailing Address: Please submit 2 money orders or certified checks with your application: $34.25 made payable to Morphotrust: Money order or Certified check Number # and $20 made payable to WV Cares: Money order or Certified check Number # If you need to change your appointment date, please call Morphotrust at Any questions regarding CBC application, please contact Dean Small (304) or dsmall@pcgus.com Public Partnerships Use ONLY Appointment Date: Appointment Time: Date of Notification of Appointment: Morphotrust Location: Notes: Revised 9/25/2017

4 SELF-DISCLOSURE APPLICATION AND CONSENT FORM (This application must be completed in blue ink) PART I I, the below-named applicant, understand that this form cannot be completed until an offer of employment is made. The offer of employment is made pending the results of the investigation of registries and a fingerprintbased background check. I understand that refusal to complete Parts I, II, and III of this form constitutes my rejection of the employment offer. I, the below-named applicant, swear/affirm, that the information contained within this application is true and correct to the best of my knowledge. Applicant Last Name: First Name: MI: Generation (ex. Jr., II): Clearly answer truthfully YES or NO to the following questions: 1. Are you addicted to alcohol, a controlled substance or a drug or are you an unlawful user thereof? 2. Have you ever been convicted of, pled guilty or nolo contendere (no contest) to a misdemeanor or felony? 3. Have you ever been convicted of an act of violence involving a deadly weapon or an act of domestic violence? 4. Are you under indictment or do you have any criminal charges pending against you? 5. Are you currently serving a sentence of confinement, parole, probation or other court ordered supervision? 6. Are you the subject of a restraining order as a result of a domestic violence act or subject to a verified petition of domestic violence or subject to a protective order? Yes No NOTE: If any questions 1-6 listed above are answered YES, a brief letter of explanation by the applicant must accompany this form. Failure to provide explanations could result in disqualification. PART II Consent for Investigation for Employment Purposes I hereby authorize the Department of Health and Human Resources (DHHR) to conduct an investigation including, but not limited to, registry and fingerprint-based background checks, into information contained in this application. I understand that my fingerprints will be retained by the West Virginia State Police for the purpose of Rap Back services during my employment in a long-term care facility. Furthermore, I understand that the falsification of any information contained within this application constitutes false swearing and is an excluding act under the fitness determination process being conducted by DHHR. Signature of Applicant: Date: (Signature must be completed in blue ink)

5 SELF DISCLOSURE APPLICATION AND CONSENT FORM (This application must be completed in blue ink) PART III Applicant Last Name: First Name: MI: Generation (ex. Jr., II): Gov t Issued ID Number: Expiration: State of Issue: Type of ID: Gender: Male Female Race: Height: ft. in. Weight: lbs. Hair Color: Brown Blonde Bald Black Gray Other Red White Eye Color: Blue Hazel Brown Red Black Other Green Gray Social Security Number: - - Date of Birth: / / Place of Birth (City & State): Citizenship: Current Mailing Address: County: Current Physical Address: County: List all cities and states (outside of WV) where you have lived within the past 5 years and provide approximate dates: List all cities and states (outside of WV) where you have worked within the past 5 years and provide approximate dates: List all names and aliases you have used formally and informally (Include maiden names, married names, nicknames, and any other name used or known as): For Office Use Only: ***This form expires 60 days after the date of the signature in Part II*** I affirm that I have compared the government issued identification presented by the applicant. Signature: Date: (Signature must be completed in blue ink) Printed Name: Position:

6 REQUEST FOR VARIANCE OF FITNESS DETERMINATION Applicant Request Date: Applicant Name: Address: City, State, Zip: Application Number: PART I Pursuant to the WV CARES Act and W.Va. St. R et seq., I request a variance of my eligibility determination. This variance is requested based on the following mitigating circumstances (check all that apply): Passage of time Extenuating circumstances such as the applicant s age at the time of conviction, substance abuse, or mental health issues Demonstration of rehabilitation such as character references, employment history, and training Relevancy of the particular disqualifying offense(s) with respect to the type of employment sought Other Please explain:

7 PART II Please provide an explanation for this variance request: Please attach additional documentation relevant to the variance request review and submit, along with this form, by to If you have any questions or require additional information, please contact our office at (304) I understand that, pursuant to the WV CARES Act and W.Va. St. R et seq., I may be provisionally employed for no more than 60 days pending the review of this variance request. Furthermore, I understand that I shall receive direct onsite supervision while the variance request is being reviewed. Signature: Date: