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State of California—Health and Human Services Agency

California Department of Public Health Licensing and Certification Program

CRIMINAL RECORD CLEARANCE SUBMISSIONS

Licensee name

Date

Facility name

Facility address

City

L&C USE ONLY Prior Conviction

LAST NAME

FIRST NAME

DATE OF

BIRTH

SOCIAL SECURITY

(mm/dd/yy)

NUMBER

POSITION/TITLE

DATE OF HIRE (mm/dd/yy)

Yes

No

Date Clearance Obtained

HAL Verification:

Signature

Date

ICF-DD INSTRUCTIONS: List all personnel of ICF/DD, ICF/DD-H and ICF/DD-N. The list must include but is not limited to the following individuals: all current and future direct care employees, including licensee personnel (including owners, all board officers, directors, LLC managers/members); administrator; any adults living at the facility; and consultants who are directly providing programs and/or nursing services to clients. If the consultants are “independent contractors” and not an employee of the facility, they are exempt from these fingerprints; however, the applicant must submit a written statement to that effect; pursuant to § 1265.5 of the Health and Safety Code the following criteria exempts consultants from background checks: 1) Is employed as a consultant and acts as direct care staff; 2) Is a registered nurse, licensed vocational nurse, physical therapist, occupational therapist, or speech-language pathologist; 3) Has obtained a criminal record clearance as a prerequisite to holding a license or certificate to provide direct care services; 4) Has a license or certification to provide direct care services that is in good standing with the appropriate licensing or certification board; 5) Is providing time-limited specialized clinical care or services; and 6) Is not alone with a client.

HHA INSTRUCTIONS: The list must include owner(s) and administrator of the private agency. The list must include individuals and owner(s) of a corporation, partnership or association having a 10% or more ownership. If the Administrator is a Doctor or Registered Nurse he or she is subject to the same requirements for a criminal records clearance.

INFORMATION COLLECTION AND ACCESS: PRIVACY STATEMENT *Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code section 17520, subdivision (d), the California Department of Public Health (CDPH) is required to collect social security numbers from all applicants for intermediate care facility licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Department of Child Support Services and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR §§ 61.1 et seq. Failure to provide your social security number will result in the return of your application. Your social security number will be used by CDPH for internal identification, and may be used to obtain criminal records or background clearances, to verify information on your application, to verify certification with another state’s certification authority, for exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.

CDPH 325 (09/09)

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