The Illinois Waiver Form is a crucial document used by health care workers in Illinois to apply for a waiver from specific disqualifications related to their criminal history. This application must be filled out completely and accurately to be considered by the Illinois Department of Public Health. It collects essential information, including personal details and work history, to assess the applicant's eligibility for employment in the health care field.
The Illinois Waiver form is a crucial document for individuals seeking employment in the healthcare sector within the state. This application, managed by the Illinois Department of Public Health, requires applicants to provide detailed personal information, including their full name, address, and social security number. It also mandates a fingerprint-based criminal history check to assess the applicant's suitability for employment. The form emphasizes transparency, as it requests information about any past criminal offenses, including those that may have involved substance abuse. Additionally, applicants must disclose their work history and any previous certifications as a nurse aide or assistant. This comprehensive approach ensures that the health care workforce maintains high standards of safety and integrity. Completing the form accurately is imperative, as it not only impacts employment opportunities but also involves legal obligations regarding the release of personal information. With the right documentation, including proof of rehabilitation or completion of any required programs, applicants can navigate the waiver process more effectively.
What is the Illinois Waiver form?
The Illinois Waiver form is an application used by health care workers to request a waiver from certain disqualifications related to their criminal history. This form is submitted to the Illinois Department of Public Health, which evaluates the applicant's suitability for employment in health care settings. It collects personal information, work history, and details regarding any criminal offenses.
Who needs to fill out the Illinois Waiver form?
Individuals applying for health care positions in Illinois who have a criminal history that may disqualify them from employment need to complete this form. This includes those who have been convicted of certain offenses or have had administrative findings of abuse, neglect, or theft. Completing the form is essential for those seeking to demonstrate their eligibility for employment despite past disqualifications.
What information is required on the form?
The form requires detailed personal information, including your name, address, Social Security number, and contact details. You must also provide a complete work history, information about any criminal offenses, and documentation regarding rehabilitation programs if applicable. Additionally, you may need to submit proof of any certifications or name changes.
How does the waiver application process work?
Once you complete the Illinois Waiver form, mail it to the Illinois Department of Public Health. After processing your application, the Department will send you a Livescan Request Form. This form allows you to have your fingerprints collected by an authorized vendor. The results of your criminal history records check will then be evaluated to determine your eligibility for a waiver.
What happens if my waiver is denied?
If your waiver application is denied, you will receive a notification explaining the reasons for the denial. You may have the opportunity to appeal the decision or provide additional information to support your case. It’s important to understand the specific reasons for the denial to address any issues effectively.
Can I include supporting documents with my application?
Yes, you can include supporting documents with your Illinois Waiver form. While not required, submitting items such as employment references, character references, or evidence demonstrating your ability to perform job responsibilities competently can strengthen your application. Keep in mind that these materials will not be returned to you.
Neglecting to provide all required information. It is essential to fill out every section of the form. Incomplete applications can delay the processing time or result in denial.
Failing to print clearly. If the form is difficult to read, it may lead to misunderstandings or errors in processing your application.
Using an incorrect name. Ensure that your name is consistent with legal documents. If you have changed your name, include supporting documents.
Omitting the Social Security number. This number is required by law and is crucial for your application. Leaving it out can lead to automatic rejection.
Not including a complete work history. You must provide a detailed account of your employment history. Attach a resume if necessary, as incomplete work history can impact your eligibility.
Overlooking to provide proof of rehabilitation. If alcohol or drugs were involved in any offenses, include documentation of successful rehabilitation.
Forgetting to attach necessary documentation. If you have certifications from other states or legal documents for name changes, ensure they are included with your application.
Not providing details for criminal offenses. If you have been convicted of a crime, you must provide comprehensive details. Incomplete information can lead to complications.
Ignoring the signature requirement. Make sure to sign and date the application. An unsigned form is considered invalid.
Failing to mail the form to the correct address. Double-check that you are sending your application to the Illinois Department of Public Health at the specified address to avoid delays.
STATE OF ILLINOIS
Illinois Department of Public Health
HEALTH CARE WORKER WAIVER APPLICATION
Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761
Phone 217-785-5133 Fax 217-524-0137 E-mail DPH.HCWR@Illinois.gov
All information requested on this application must be provided before you will be considered for a waiver. Type or print clearly in ink.
Today’s Date
Name
(First, Full Middle and Last)
Address
(Street, Apartment #, P. O. Box)
(City, State, ZIP Code)
Maiden Name (or other name(s) used)
Telephone
Social Security Number (required)
I hereby authorize the Illinois Department of Public Health, the Department’s designee that trains or tests health care workers, a staffing agency, or the health care employer to request a fingerprint-based criminal history records check submitted as a fee applicant inquiry requested by the Department. I further authorize the Illinois State Police (ISP) to release information relative to the existence or nonexistence of any criminal record which it might have concerning me to the requestor solely to determine my suitability for employment or continued employment. I further authorize any agency that maintains records relating to me, including but not limited to the Federal Bureau of Investigation or a local unit of government, to provide same on request to the ISP or the Department. I certify that the ISP and any agency, including the Department, their employees or officers who furnish this information shall be held harmless from any and all liability which may be incurred as a result of releasing such information. I further acknowledge that a health care employer shall not be liable for the failure to hire or retain an applicant or employee who has been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).
I understand that the information requested below regarding sex, race, height, eye color, and date of birth is for the sole purpose of identification, the gathering of the above mentioned information and the processing of this waiver application. This information will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.
Male
Female Race
Height
Eye Color
Date of Birth
(Enter a letter from below):
AChinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander B Black or African American (Not Hispanic or Latino)
H Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) I American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states
of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition. U Of undetermined race or of untold mixture
W Caucasian (not Hispanic or Latino)
Work History – If you have previously been employed, you must provide an entire work history or attach a complete resume. Start with your current employer. Attach addition pages if necessary.
Employer
Date Started
Separation Date
Employer’s Address, City, State, ZIP Code
Other states where you have lived or worked
If the use of alcohol or other drugs was involved in the offense, were you ordered to participate in a rehabilitation program as part of the
judgment?
Yes
No
If yes, you must provide proof of successful completion of the rehabilitation program.
Were you required to pay a fine in connection to a disqualifying offense?
If yes, you must provide
proof of having paid all fines unless you are on a payment schedule. If on a payment schedule, you must provide proof that you are up-to- date on the schedule.
If you were released on probation (or mandatory supervised release) or parole, you must provide proof of having successfully completed it.
Have you been certified as a nurse aide/assistant in another state?
If yes, you must attach a copy of
your certification or verification information (such as your certification number__________________________________).
Name used when certified_____________________________________________. If your current name is different, please attach a copy
of the legal document(s) used to change your name (i.e. marriage certificate, divorce decree, etc.) and a copy of your driver’s license or other picture identification.
Have you ever had an administrative finding of abuse, neglect or theft?
If “yes,” indicate in what state this finding was issued.
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
If “yes,” provide the circumstance surrounding each offense (what happened, how many years have passed since the offense, the individuals involved, your age at the time of the offense, and any other circumstances surrounding the offense) as well as the state in which you were convicted. If you have been convicted in another state, you must provide information concerning those convictions or attach the complete results of a criminal history records check from that state. If you have a federal conviction, you must provide information concerning that conviction or attach the complete results of a criminal history records check from the Federal Bureau of Investigation. If more space is needed, please attach additional pages. Do not include convictions that have been expunged, sealed or were a juvenile adjudication.
A copy of the following items may be submitted with this application but are not required. (This material will not be returned to you)
1.A current or recent employment reference.
2.A character reference.
3.Other evidence demonstrating the ability of the applicant to perform the employment responsibilities competently and evidence that the applicant does not pose as a threat to the health or safety of residents, patients or clients.
I certify that the above is true and correct and give my consent for my name to appear on the Department’s Health Care Worker Registry with the results of my criminal history records check.
Signature
Date
As the parent or guardian of the above named individual, who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.
Mail this completed form to Illinois Department of Public Health, Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761. The Department will send you a Livescan Request Form by return mail. You will use the Livescan Request Form to have your fingerprints collected from one of the contracted livescan vendors.
When filling out the Illinois Waiver form, it's crucial to be thorough and accurate. Here are four essential dos and don’ts to keep in mind:
Paying attention to these guidelines can significantly streamline your application process. Take the time to double-check your form before submission to ensure everything is in order.
The Illinois Waiver form is a crucial document for health care workers seeking to obtain a waiver from certain disqualifications related to their criminal history. Alongside this form, several other documents may be required or beneficial to complete the application process. Below is a list of common forms and documents that often accompany the Illinois Waiver form.
Having these documents prepared can streamline the waiver application process and improve the chances of a favorable outcome. Always ensure that all forms are completed accurately and submitted on time to avoid delays in processing.
Understanding the Illinois Waiver form is crucial for those navigating the health care worker registration process. However, several misconceptions can lead to confusion. Here are eight common misunderstandings:
Being aware of these misconceptions can help individuals better prepare for the waiver application process and ensure compliance with all requirements.
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