Form Cca – Fill Out and Use This PDF

IMPORTANT NOTICE: Completion of this

SUPPORTING DOCUMENT

form is necessary to accomplish the

HEALTH CARE WORKERS

requirements outlined in 225 of the Illinois

Compiled Statutes. Disclosure of this

CHARGED WITH OR CONVICTED

CCA

information is VOLUNTARY. However, failure

OF CRIMINAL ACTS

to comply may result in this form not being

processed.

1.

NAME

LAST

FIRST

MIDDLE

3.

PROFESSIONAL LICENSE NUMBER (if any)

__ __ __ - __ __ __ __ __ __

2.

ADDRESS

STREET, CITY,

STATE,

ZIP CODE

4.

SOCIAL SECURITY NUMBER

__ __ __ - __ __ - __ __ __ __

Pursuant to 20ILCS 2105-165(a), the Department requires the following professionals to disclose information regarding

convictions pertaining to certain offenses. Please check applicable profession.

Acupuncturists

Naprapaths

Physician Assistants

Advanced Practice Nurses

Nursing Home Administrators

Podiatrists

Athletic Trainers

Occupational Therapists

Professional Counselors

Audiologists

Occupational Therapy Assistants

Prosthetists

Clinical Psychologists

Optometrists

Registered Nurses

Clinical Social Workers

Orthotists

Registered Surgical Assistants

Dental Hygienists

Pedorthists

Registered Surgical Technologists

Dentists

Perfusionists

Respiratory Care Practitioners

Genetic Counselors

Pharmacists

Speech Pathologists

Licensed Clinical

Physical Therapists

Professional Counselors

Physical Therapy Assistants

Licensed Practical Nurses

Physicians, including Medical Doctors

Licensed Social Workers

(M.D.), Doctors of Osteopathic Medicine

Marriage and Family Therapists

(D.O.), and Chiropractic Physicians (D.C.)

Any other license issued by the Department under the Acts listed in this Section and the Controlled Substances Act

[740 ILCS 40], except for pharmacy technicians, issued to a person subject to the Code and this Part.

In order for your application to be evaluated, you must respond to each of the following questions:

1) Are you currently charged with or have you been convicted of a criminal act that requires registration

Yes

No

under the Sex Offender Registration Act? *

2) Are you currently charged with or have you been convicted of a criminal battery against any patient in the course of patient care or treatment, including any offense based on sexual conduct or sexual penetration?

3) Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? *

4) Are you currently charged with or have you been convicted of a forcible felony? *

If YES to any of the above, attach a certified copy of the court records regarding your conviction, the nature of the offense and date of discharge, if applicable, as well as a statement from the probation or parole office.

Certification Statement

Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or information submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

Signature of Applicant

Date

IL486-2034 02/13 (crimacts)

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* DEFINITIONS

730 ILCS 150 et. seq:—Acts that require Sex Offender Registration:

(B)As used in this Article, “sex offense” means:

(1)A violation of any of the following Sections of the Criminal Code of 1961:

11-20.1 (child pornography),

11-20.3 (aggravated child pornography),

11-6 (indecent solicitation of a child),

11-9.1 (sexual exploitation of a child),

11-9.2 (custodial sexual misconduct),

11-9.5 (sexual misconduct with a person with a disability), 11-15.1 (soliciting for a juvenile prostitute),

11-18.1 (patronizing a juvenile prostitute),

11-17.1 (keeping a place of juvenile prostitution),

11-19.1 (juvenile pimping),

11-19.2 (exploitation of a child),

11-25 (grooming),

11-26 (traveling to meet a minor),

12-13 (criminal sexual assault),

12-14 (aggravated criminal sexual assault),

12-14.1 (predatory criminal sexual assault of a child), 12-15 (criminal sexual abuse),

12-16 (aggravated criminal sexual abuse),

12-33 (ritualized abuse of a child). An attempt to commit any of these offenses.

(1.5) A violation of any of the following Sections of the Criminal Code of 1961, when the victim is a person under 18 years of age, the defendant is not a parent of the victim, the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act, and the offense was committed on or after January 1, 1996:

10-1 (kidnapping),

10-2 (aggravated kidnapping),

10-3 (unlawful restraint),

10-3.1 (aggravated unlawful restraint).

(1.6) First degree murder under Section 9-1 of the Criminal Code of 1961, when the victim was a person under 18 years of age and the defendant was at least 17 years of age at the time of the commission of the offense, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.

(1.7) (Blank).

(1.8) A violation or attempted violation of Section 11-11 (sexual relations within families) of the Criminal Code of 1961, and the offense was committed on or after June 1, 1997.

(1.9) Child abduction under paragraph (10) of subsection (b) of Section 105 of the Criminal Code of 1961 committed by luring or attempting to lure a child under the age of 16 into a motor vehicle, building, house trailer, or dwelling place without the consent of the parent or lawful custodian of the child for other than a lawful purpose and the offense was committed on or after January 1, 1998, provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act.

(1.10) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on or after July 1, 1999:

10-4 (forcible detention, if the victim is under 18 years of age), provided the offense was sexually motivated as defined in Section 10 of the Sex Offender Management Board Act,

11-6.5 (indecent solicitation of an adult),

11-15 (soliciting for a prostitute, if the victim is under 18 years of age), 11-16 (pandering, if the victim is under 18 years of age),

11-18 (patronizing a prostitute, if the victim is under 18 years of age), 11-19 (pimping, if the victim is under 18 years of age).

(1.11) A violation or attempted violation of any of the following Sections of the Criminal Code of 1961 when the offense was committed on or after August 22, 2002:

11-9 (public indecency for a third or subsequent conviction).

(1.12) A violation or attempted violation of Section 5.1 of the Wrongs to Children Act (permitting sexual abuse) when the offense was committed on or after August 22, 2002.

(2)A violation of any former law of this State substantially equivalent to any offense listed in subsection (B) of this Section.

(C)A conviction for an offense of federal law, Uniform Code of Military Justice, or the law of another state or a foreign country that is substantially equivalent to any offense listed in subsections (B), (C), (E), and (E5) of this Section shall constitute a conviction for the purpose of this Article.

IL486-2034 02/13 (crimacts)

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* DEFINITIONS

A “forcible felony”, for the purposes of Section 2105-165 of the Code (section numbers are from the Criminal Code of 1961 [720 ILCS 5]) and 68 Illinois Administrative Code 1130.120 is one or more of the following offenses:

a)First Degree Murder (Section 9-1);

b)Intentional Homicide of an Unborn Child (Section 9-1.2);

c)Second Degree Murder (Section 9-2);

d)Voluntary Manslaughter of an Unborn Child (Section 9-2.1);

e)Drug-induced Homicide (Section 9-3.3);

f)Kidnapping (Section 10-1);

g)Aggravated Kidnapping (Section 10-2);

h)Unlawful Restraint (Section 10-3);

i)Aggravated Unlawful Restraint (Section 10-3.1);

j)Forcible Detention (Section 10-4);

k)Involuntary Servitude (Section 10-9(b));

l)Involuntary Sexual Servitude of a Minor (Section 10-9(c));

m)Trafficking in Persons (Section 10-9(d));

n)Criminal Sexual Assault (Section 11-1.20);

o)Aggravated Criminal Sexual Assault (Section 11-1.30);

p)Predatory Criminal Sexual Assault of a Child (Section 11-1.40);

q)Criminal Sexual Abuse (Section 11-1.50);

r)Aggravated Criminal Sexual Abuse (Section 11-1.60);

s)Aggravated Battery (Section 12-3.05);

t)Compelling Organization Membership of Persons (Section 12-6.5);

u)Compelling Confession or Information by Force or Threat (Section 12-7);

v)Home Invasion (Section 12-11);

w)Robbery (Section 18-1);

x)Armed Robbery (Section 18-2);

y)Vehicular Hijacking (Section 18-3);

z)Aggravated Vehicular Hijacking (Section 18-4);

aa)Aggravated Robbery (Section 18-5);

bb)Terrorism (Section 29D-14.9);

cc)Causing a Catastrophe (Section 29D-15.1);

dd)Possession of a Deadly Substance (Section 29D-15.2);

ee)Making a Terrorist Threat (Section 29D-20);

ff)Falsely Making a Terrorist Threat (Section 29D-25);

gg)Material Support for Terrorism (Section 29D-29.9);

hh)Hindering Prosecution of Terrorism (Section 29D-35);

ii)Boarding or Attempting to Board an Aircraft with Weapon (Section 29D-35.1);

jj)Armed Violence (Section 33A-2); and

kk)Attempt (Section 8-4) of any of the above specified offenses.

IL486-2034 02/13 (crimacts)

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