CHRC 103 Form – Fill Out and Use This PDF

DOH CHRC 103 (9/06) – Page 1

This form is to be used to request a criminal history record check (CHRC) for a subject individual from the DOH CHRC Unit.

For purposes of this form, the term “Agency” means residential health care facility, certified home health agency, licensed home care services agency or long term home health care programs that are authorized by law to request a check of criminal history record information pursuant to Article 28-E of

the Public Health Law and Section 845-b of the Executive Law.

“Authorized Person” is the individual that is allowed to request, on behalf of the Agency, fingerprints and criminal history record checks.

“Subject individual” is an “employee” as defined by Public Health Law Section 2899(3).

INSTRUCTIONS:

1.This form is to be completed by the Authorized Person, who will sign and date where indicated in Section 3.

2.Please obtain subject individual information and complete all sections on page 2 of this form prior to or at the time of fingerprinting. This information will be used to conduct both a Federal and State criminal history record check pursuant to State law.

3.If subject individual is employed by a staffing organization with an Agency work location, the Agency is responsible for completing this form and the staffing agency may complete Section 4 if that staffing agency fingerprints the subject individual.

4.Subject individual is required to present two (2) forms of identification (ID) when fingerprinted. One must be a government-issued ID with subject individual’s signature. At least one of the two forms of ID must contain a current photograph. Acceptable forms of government-issued IDs are: valid driver’s license or Department of Motor Vehicles (DMV) ID, valid passport, valid military identification or valid school identification document. The type of government-issued ID presented is recorded in Section 2 of this form. Refer to the Employment Eligibility Verification Form I-9 for examples of other forms of identification. The second ID must be produced but not recorded in Section 2 of this form.

5.If subject applicant is fingerprinted by other than the Authorized Person, provide this instructional page to that individual for assistance in completing Section 4 of this form.

6.Authorized Person is to ensure that all fields in all sections must be completed for accurate and timely submissions.

7.Authorized Person will forward Page 2 of this Form to the DOH CHRC Unit at the address indicated above.

FIELD DESCRIPTIONS:

BIRTH COUNTRY/PLACE FIELD

Enter United States of America for those of American birth

Enter Country of Birth for those not of American birth

HEIGHT FIELD

To be completed as a three (3) character value. If reported in feet and inches, the first (leftmost) digit is used to show feet with the two rightmost digits are used to show the inches between 00 and 11. If reported in inches, the leftmost character is “N” followed by two digits. If height in unknown,

000 is entered.

The allowable range is 400 to 711. Heights shorter than 4 ft. will be recorded as 400 and taller than 7 ft. 11 in. will be recorded as 711.

WEIGHT FIELD

In this field, the subject applicant’s weight in pounds is entered (000-499). If weight is unknown, 000 is entered.

All weight in excess of 499 pounds will be recorded as 499 lbs.

HAIR FIELD – COLOR CODES	EYE FIELD – COLOR CODES
BAL – Bald	BLK – Black
BLK – Black	BLU – Blue
BLN – Blonde or Strawberry	BRO – Brown
BLU – Blue	GRY – Gray
BRO – Brown	GRN – Green
GRN – Green	HAZ – Hazel
GRY – Gray or Partially Gray	MAR – Maroon
ONG – Orange	MUL – Multicolored
PNK – Pink	PNK – Pink
PLE – Purple	XXX – Unknown
RED – Red or Auburn
SDY – Sandy
WHI – White
XXX – Unknown