Name:

UMID #:

University of Michigan Health System

Background Check Information, Consent and Disclosure
The University of Michigan Health System assures the integrity of its workforce and protects its patients
in part by conducting (directly or through third-party vendors) background checks on faculty, staff,
volunteers and, in some cases, contractors. Individual background checks currently consist of:

Social Security Number verification (used to verify a persons identity)

International, federal, state, and local criminal records, wants and warrants searches
Sex offender registry searches
A search of the Fraud and Abuse Control Information System (FACIS) system, which tracks
federal health care fraud and federal contractor sanctions.

Additional checks (e.g., employment history, verification of licensure and training information, review of
National Practitioner Data Bank entries, and so forth) may be conducted in connection with any faculty
appointment or Medical Staff members application for membership and clinical privileges, or with the
employment of any other licensed, registered or certified health professional. None of these background
checks include credit checks or other reviews of financial status or history unless your job classification or
volunteer or contractor assignment requires such a check under applicable law or U-M policy and you
have or later do separately consent to it in writing (paper or electronic).
In addition to these general background checks, Michigan law currently requires long-term care facilities,
psychiatric facilities, home health agencies, and other health care providers to conduct criminal
background checks (including fingerprint screens) on all employees and contractors with regular, direct
access to their patients or patients financial, health or other identifiable information. Thus, some UMHS
employees, volunteers, contractors, or applicants must submit to fingerprint screens in addition to the
general
background
checks,
which
are
described
further
below
and
at
http://www.michigan.gov/mdch/0,1607,7-132-27417-138762--,00.html.
In the event of any change in Michigan law that requires additional checks, all affected current workforce members
and prospective applicants will be notified of the change and will be required to consent to those additional checks as
a condition of continued employment.

Part 1 Demographic Information (type or print clearly):

First Name

Middle Name

Date of Birth

Place of Birth

Hair Color

Eye Color

Street Address

Last Name

Maiden Name/All Other Aliases

Country of Citizenship (LIST ALL)

Height

Weight

Gender

Race

SSN

City

State

Zip Code

County of Residence

Phone Number

Reside in MI last 12 months

List All Other Addresses Where You Have Lived

During the Past Seven (7) Years (Attach an Additional
Sheet if Necessary)
If You Have Lived Abroad, Include Your Fathers Full
Name and Address.

Drivers License Number

State

v.1.4-March 2011

Page 1 of 6

Name:

UMID #:

Part 2 Consent
As a condition of being considered for a new or continued position at the University of Michigan Health
System (UMHS) as an employee, volunteer, or contractor:
1.

I hereby consent to and authorize UMHS or its agents or contractors to conduct background checks as
described above, including:
Verification of information submitted to UMHS, e.g., in applications or on this form
Searches of state and federal abuse and neglect registries and databases
Searches of state and federal criminal history records that, depending on my job
classification, may include fingerprint-based checks
I understand that this consent extends to the release and sharing of such information with the
Michigan Departments of Community Health, Human Services, Corrections, and State Police.

2.

I hereby authorize the release of any relevant information to UMHS or its agents or contractors to be
used to conduct the background check as required under UMHS policy and/or Michigan Public Acts
27, 28 and 29 of 2006 or other applicable law.

3.

I understand that UMHS will make the final employment, volunteer, or contracting determination
subject to the requirements of applicable law. I also understand that UMHS may terminate the
background check or determine not to hire or retain at any stage of the process.

4.

I understand that federal and state laws such as the federal Fair Credit Reporting Act (FCRA) may
provide me with certain rights regarding the accuracy, fairness, and privacy of information collected
and used through the UMHS background check program. I understand that information about the
FCRA
is
available
at
http://www.ftc.gov/credit
and
http://www.ftc.gov/bcp/conline/pubs/credit/fcrasummary.pdf.

5.

I understand that UMHS, in denying employment or other position to an applicant, and reasonably
relying on information obtained through a background check, is provided immunity from any action
brought by an applicant due to the decision. I hearby further release the University and any of its
agents and contractors from any other liability that may be incurred in connection with their review
and use of information about me collected through the background check program, except in cases of
gross negligence or intentional misconduct.

Signature of Applicant/Employee/Volunteer/Contractor

Date

Part 3 Disclosures
1.

I certify that, if I am subject to the requirements of PA 27, 28, or 29 of 2006, I have not been convicted
of a crime or offense that prohibits my employment, hire, or granting of clinical privileges in a longterm care setting as required by PA 27, 28 and 29 of 2006, within the applicable time period
prescribed by each crime. I can find out whether I am subject to PA 27, 28, or 29 of 2006 by
contacting: (734) 647-5538. A current list of the relevant crimes and offenses is available in the Legal
Guide posted at: http://www.miltcpartnership.org/MainSite/W1.aspx.
I understand that
conviction of one of the listed crimes is good cause for termination of employment, contract, or status.

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Page 2 of 6

Name:

Signature of Applicant/Employee/Volunteer/Contractor
2. I certify that (choose one option below):

UMID #:

Date

I have never been convicted, pled guilty, or pled nolo contendere to any crime. No
substantiated finding of patient or resident neglect, abuse, or misappropriation of property
has ever been made against me by a federal or state agency, an employer, or any other
agency or entity. I have never been sanctioned for federal health care program or federal
contractor fraud, abuse, or misconduct. I have never pled not guilty by reason of insanity
or an equivalent defense and I have never been subject to an order or disposition of not
guilty by reason of insanity or equivalent order or disposition for any crime.
The list below in Section 3 of my convictions, guilty pleas, nolo contendere pleas; substantiated
findings against me of patient or resident neglect, abuse, or misappropriation of property;
sanctions for federal health care program and federal contractor fraud, abuse and
misconduct; and not guilty by reason of insanity pleas, orders, or dispositions is true,
correct, and complete to the best of my knowledge.

Signature of Applicant/Employee/Volunteer/Contractor
3.

Date

I disclose, by listing below:

All offenses for which I have been convicted, pled guilty, or pled nolo contendere, including all
terms and conditions of sentencing, parole and probation.
Any substantiated finding (whether by a court, an employer, or otherwise) of patient or
resident neglect, abuse, or misappropriation of property.
Any instance of federal health care program or federal contractor fraud, abuse, or misconduct
for which sanctions have been imposed.
Any instance when I pled not guilty by reason of insanity and any instance in which I was
subject to an order or disposition of not guilty by reason of insanity for any crime.
Offense

Date and Type of

Conviction/
Plea/Disposition

Location
(City, State, Country)

Signature of Applicant/Employee/Volunteer/Contractor

v.1.4-March 2011

Sentence/Sanction

Date of
Discharge

Date

Page 3 of 6

Name:

UMID #:

Part 4 Conditional Employment

If the University of Michigan Health System decides to employ or retain me, or grant me clinical
privileges pending the results of the background checks described above on page 1, I understand the
following:
1.

Inaccurate or incomplete disclosures are good cause for termination of employment, contract, and/or
clinical privileges. If the background check does not confirm my disclosure statements made above,
my employment, contract, and/or clinical privileges may be terminated, unless I successfully prove
that the disqualifying information is inaccurate. I may also be subject to criminal sanctions.

2.

As a condition of my continued employment or work at UMHS or continued medical staff

membership and clinical privileges, I will report in writing to the University of Michigan Health
System Compliance Office and my supervisor (or, in the case of a faculty member, my Department
Chair) immediately if:
Any information provided in Part 3 above changes; or
I am arraigned for any crime described in the Legal Guide available at
http://www.miltcpartnership.org/MainSite/W1.aspx; or
I am notified of any government investigation of me in connection federal health care
programs or federal contracts.
I understand that reporting such an event is not necessarily cause for termination or denial of
employment or privileges; but failure to make a timely report may result in disciplinary action
against me up to and including dismissal (and/or, as applicable suspension or revocation of clinical
privileges).

Signature of Applicant/Employee/Volunteer/Contractor

Date

Part 5 Applicant Rights

1.

I understand that at my request, UMHS will provide a copy of any disqualifying record information
found on any of the relevant registries or databases.

2.

I understand that if I believe the results of any disqualifying record information found on any
relevant registry or database is inaccurate, it is my responsibility to correct the record information by
directly contacting the appropriate registry/database owner.

3.

I understand that if I believe the results of the criminal history fingerprint record are inaccurate, or if
a conviction contained in the criminal history record is one that may be expunged or set aside, I may
file an appeal of any statutory work disqualification to the appropriate state licensing or regulatory
department.

Signature of Applicant/Employee/Volunteer/Contractor

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Date

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UMID #:

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