Background Check Form

Pursuant to Title 10, Section 400.23 of the New York Code of Rules and Regulations, Crest Manor Living & Rehabilitation Center, Inc. is required to conduct a criminal background check of all applicants for employment in non-licensed positions providing direct residential care and/or supervision. Pursuant to these regulations we are required to notify you of the following:

1. We will submit your fingerprints to the New York State Department of Health and request the Department to forward such information to the Attorney General of the United States. The Attorney General will then conduct a full search of the records of the Federal Bureau of Investigation to ascertain if you have any record of a criminal conviction.
2. The Attorney General will provide its findings to the New York State Department of Health, which will in turn forward the results to us. If the background check reveals that you have been convicted of certain enumerated crimes, your application for employment will be rejected. If you have been offered provisional employment, such employment will be terminated.
3. Pursuant to the regulations, you have the right to:
   1. a. Obtain a copy of the results of the criminal background check, review the information contained and explain same;
   2. b. Withdraw your application for employment without prejudice at any time before we make a decision on your application. In such event we will destroy your fingerprint card and any information we may have obtained in connection with the criminal background check.
4. The fingerprinting and criminal background checks are conducted at no cost to you.
5. Any information we receive about you as a result of a criminal background check will be used only for determining your suitability for employment in a position involving direct patient care or supervision. Such information will be treated as confidential and will not be disclosed to any one else except as permitted by law.
6. If your employment application is denied because of information obtained during the course of a criminal background check we will provide you with a written statement of our decision and the basis thereof.

I HAVE RECEIVED A COPY OF THIS NOTICE OF CRIMINAL BACKGROUND CHECK ON THE DATE SET FORTH BELOW.