CHRC 103 Form PDF Details

The necessity for stringent background checks within healthcare settings is underscored by the importance of maintaining a secure and trustworthy environment for both patients and staff. Against this backdrop, the CHRC 103 form emerges as a crucial tool, operational under the purview of the New York State Department of Health's CHRC Unit. Serving a wide array of agencies, including residential health care facilities and home care services among others, this form facilitates the request for a comprehensive criminal history record check (CHRC) for individuals seeking employment within these sensitive spheres. By mandating detailed information and requiring fingerprints for both state and federal checks, the form is designed to uphold high standards of care and safety. With specific provisions for identifying the subject individual through multiple forms of ID, and clear instructions for both the requesting agencies and the individuals performing the fingerprinting, the CHRC 103 form ensures a thorough vetting process. This process not only supports legal compliance but also reinforces the commitment to safeguarding the well-being of the most vulnerable populations, thus playing a pivotal role in the healthcare sector’s employment procedures.

QuestionAnswer
Form Name CHRC 103 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names nys doh chrc 103, chrc 103 form, doh, doh chrc form 103 printable

Form Preview Example

DOH CHRC 103 (9/06) – Page 1

NYS Department of Health

CHRC Unit

P. O. Box 2607

Albany, NY 12220-0607

Phone: 518.402.5549

Fax: 518.474.7477

www.nyhealth.gov/chrc

chrc@health.state.ny.us

REQUEST FOR

CRIMINAL HISTORY RECORD CHECK

PAGE 1

INSTRUCTIONS

CRIMINAL HISTORY RECORD CHECK

(CHRC)

PROGRAM

For Department use only

Leave blank

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:

SEX FIELD

MMale F Female

RACE FIELD

A Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan or any other Pacific Islander

B African black racial groups

IAmerican Indian, Eskimo, or Alaskan native U Of indeterminable race

W Caucasian, Mexican, Puerto Rican, Cuban, Central/South American or other Spanish origin

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

 

DOH CHRC 103 (9/06) - Page 2

51289

NYS Department of Health

CRIMINAL HISTORY RECORD CHECK

Resubmission

Type or print all information - USE CAPITAL LETTERS.

 

 

 

Inaccurate, incomplete or

illegible

information will delay processing.

 

DOH use only. Leave blank

 

 

SECTION 1 - SUBJECT INDIVIDUAL INFORMATION

 

 

Social Security Number*

-

-

Date of Birth mm/dd/yyyy

/

/

LAST Name

 

 

 

FIRST Name

 

 

M.I.

Maiden Name

 

 

Alias (AKA)

 

 

 

Street

 

Street

 

 

 

 

Apt #

Nmbr

 

Name

 

 

 

 

 

 

 

 

 

 

City

 

 

St

Zip

Home

-

-

 

 

Phone

Sex

Birth

 

 

 

Cell

-

-

 

Country/Place

 

 

 

Phone

 

 

 

 

 

 

Race

Height (ft-inch)

-

Weight (lbs)

Hair

Eyes

 

 

SECTION 2 - SUBJECT INDIVIDUAL IDENTIFICATION

Please Select the Type of PICTURE IDENTIFICATION (select one):

 

Drivers License/

Passport

Miltary

School

Other Identify:

DMV ID

 

 

 

 

Issuing State/Country/Armed Force/School:

 

ID Number

ID Expire Date mm/dd/yy

/ /

SECTION 3 - AGENCY IDENTIFICATION

Nursing

CHHA

LTHHCP PFI#

Home

 

 

Full name of Agency where applicant will be working

LHCSA LICENSE #

Telephone number with area code

- -

Authorized Person LAST Name

Agency's

Street Nmbr

City

Authorized Party's e-mail:

FIRST

Name

Street

Name

State

Zip

The subject individual, whose identification I have confirmed, will provide direct care or supervision to individuals receiving care and/or services and is a subject individual concerning whom a criminal history record check is required by law (Article 28-E of the Public Health Law and Section 845-B of the Executive Law). I understand that the results of the criminal history record check will be used solely for purposes authorized by law and I will abide by the confidentiality requirements set forth in law. Informed consent (DOH CHRC Form 102) has been given by the subject individual and is on file.

Signature of Agency Authorized Person:

Date:

/

MM

/

DD YY

SECTION 4 - FINGERPRINTING METHOD/IDENTIFICATION

Fingerprint Method:

Name & Address of

 

 

 

 

 

 

 

 

 

 

 

Ink & Roll

Location where fingerprint

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Live Scan

services were performed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

Identification verified

The subject individual, whose identification

 

Date Fingerprinted

before fingerprinting:

I have confirmed, appeared before me for

 

 

/

/

 

 

 

 

 

 

 

(refer to Instruction

fingerprinting. I secured his/her fingerprints

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

 

 

#4)

via the method indicated.

MM

DD

 

 

 

Y Y Y Y

 

 

 

 

 

 

 

 

 

 

 

 

Yes

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51289

*The Authorized Person shall inform the subject individual that disclosure of the Social Security Number (SSN) is voluntary and not mandatory and that it will be used to assist DOH-CHRC Unit in performing criminal history record checks.

103 v11

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nys doh chrc 103 writing process detailed (part 1)

2. Soon after finishing the last part, go on to the next part and enter the necessary details in these fields - Nursing Home Full name of Agency, Authorized Person LAST Name, Agencys Street Nmbr, City, Authorized Partys email, Street Name, FIRST Name, Telephone number with area code, State, Zip, The subject individual whose, Signature of Agency Authorized, Date, SECTION FINGERPRINTING, and Fingerprint Method.

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