The CHRC 103 form serves as the primary mechanism through which the New York State Department of Health verifies the background of individuals seeking employment in sensitive healthcare settings. New York State Public Health Law mandates that agencies providing residential or home-based care conduct criminal history record checks before any individual is hired to work with patients or clients.
The following types of agencies are required to submit this form for new hires: residential health care facilities, certified home health agencies, long-term home health care programs, home care services agencies, hospice programs, AIDS home care programs, and licensed home care services agencies. Any authorized representative of these agencies may initiate a check on behalf of a prospective or current employee.
The form requires agencies to provide identifying details about the subject individual, including full name, date of birth, and Social Security Number along with at least one additional government-issued photo ID such as a driver’s license or passport number. The authorized person completing the form must include their own agency details, direct contact information, and a dated signature. Incomplete or unsigned submissions are returned without processing, which may delay a hiring decision.
One of the distinguishing features of the CHRC process is the requirement for fingerprint-based checks at both the state and federal levels. The fingerprinting must be performed by an approved technician, and the form includes a dedicated section identifying the method used. Both ink-card and live-scan electronic fingerprinting are accepted depending on what the agency has arranged with an approved provider.
For agencies that hire staff regularly in home care or residential settings, having a completed template on file can speed up the onboarding process. You may also find useful our background check consent form and employee reference check template, which are commonly used alongside the criminal history check process.
| Question | Answer |
|---|---|
| Form Name | CHRC 103 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Issuing Agency | New York State Department of Health, CHRC Unit |
| Who Must File | Authorized representatives of licensed healthcare agencies in New York |
| Jurisdiction | New York State |
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