Background Check and Drug Screen

Notification and Authorization to Release Criminal Information for Employment Purposes



The position for which I am being considered requires me to consent to a criminal background check  and drug screen as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided. The drug screen is completed through Quest Diagnostics. 


I hereby authorize Assist Medical Staffing to conduct the criminal background check and drug screen described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist Assist Medical Staffing in collecting this information. VICTIG has been secured as a third party vendor (consumer reporting agency) to assist Assist Medical Staffing in collecting and verifying information. I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment. Such information will be used to determine whether the results of the background check reasonably bear on my trustworthiness or my ability to perform the duties of my position in a manner which is safe for Assist Medical Staffing patients and clients.

Please print (for identification purposes):


Other Names:

Birth Date:

Gender: Gender:

Social Security Number:


City: State: Zip Code:  

Have you ever been convicted of a criminal *offense or have any pending criminal* charges
against you?

*This refers only to felonies and misdemeanors; you do not need to include non-criminal traffic
violations or municipal ordinance violations.

To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete. I understand there will be a fee of thirty-eight dollars deducted from my first payroll for the Quest Diagnostics drug screen. I understand that any falsification or omission of information may disqualify me for this position and/or may serve as grounds for the severance of my employment with Assist Medical Staffing. By signing below I hereby provide my authorization to Assist Medical Staffing to conduct a criminal background check and drug screen and I acknowledge that I have been provided with a summary of my rights under the Fair Credit Reporting Act which is attached. In addition to those rights, I understand that I have a right to appeal an adverse employment decision made by Assist Medical Staffing based on my background check information within three business days of receipt of such notice and that a determination on my appeal will be made in seven working days from Assist Medical Staffing's receipt of such appeal.

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Signature Certificate
Document name: Background Check Release
lock iconUnique Document ID: d2f4c4305b11b5ef8c84ea6b8fee2777b8f33d32
Timestamp Audit
January 24, 2023 4:43 pm EDTBackground Check Release Uploaded by Assist Medical Staffing - IP
February 6, 2023 1:16 pm EDT Document owner has handed over this document to 2023-02-06 13:16:11 -