New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 48A - BACKGROUND CHECKS › Subchapter 3 - PROCEDURES › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
CERTIFICATION AND PERMISSION FOR BACKGROUND CHECK AND RELEASE
				  OF INFORMATION
I hereby authorize the Department of Human Services to
				  conduct a criminal history background check and I agree to be fingerprinted in
				  order to complete the State and Federal background check process. I further
				  authorize the release of all information regarding the results of my background
				  check to the Department of Human Services. Check one of the options listed
				  below.
Option 1 _____I hereby certify under penalties of perjury,
				  that I have not been convicted of any of the offenses listed below and no such
				  record exists in the State Bureau of Identification in the Division of State
				  Police or in the Federal Bureau of Investigation, Identification
				  Division.
Option 2 _____ I hereby affirm that I have been
				  convicted
of the following offense listed below
				  _____________________
on ___________________
(date)
If I have checked Option 2 or the criminal history background
				  check reveals any conviction(s) for the offenses listed below, I understand
				  that I may be subject to termination from employment, or if I am associated
				  with a community care residence, the residence will not be qualified to house
				  individuals.
FOR PROVISIONAL EMPLOYEES ONLY: As a provisional employee, I
				  further understand that I may be employed by the agency for a period not to
				  exceed six months during which time a background check will be completed. I
				  understand that I will work under the supervision of a superior where
				  possible.
Offenses covered under
				  P.L.
				  1999, c. 358:
In New Jersey, any crime or disorderly person offense:
--involving danger to the person as set forth in
				  N.J.S.A.
				  2C:11-1 et seq. through 2C:15-1 et seq.
				  including the following:
i. Murder
ii. Manslaughter
iii. Death by auto
iv. Simple assault
v. Aggravated assault
vi. Recklessly endangering another person
vii. Terroristic threats
viii. Kidnapping
ix. Interference with custody of children
x. Sexual assault
xi. Criminal sexual contact
xii. Lewdness
xiii. Robbery
--against the children or incompetents as set forth in
				  N.J.S.A.
				  2C:24-1 et seq. including the
				  following:
i. Endangering the welfare of a child
ii. Endangering the welfare of an incompetent person
--a crime or offense involving the manufacture,
				  transportation, sale, possession or habitual use of a controlled dangerous
				  substance as defined in
				  N.J.S.A.
				  2C:24-1 et seq.
--in any other state or jurisdiction, conduct which, if
				  committed in New Jersey, would constitute any of the crimes or disorderly
				  persons offenses described above.
FOR COMMUNITY AGENCY HEAD: I understand the results of this
				  background check will be reported to the President of the Board of my
				  agency.
PLEASE LIST THE NAME AND HOME OR BUSINESS ADDRESS OF THE
				  BOARD PRESIDENT.
____________________________________
____________________________________
____________________________________
_________ _______________ ____________
Name (please print) Signature Date
_________ _______________ ____________
Witnessed by (please print) Witness Signature
				  Date