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Fill a Valid Illinois Waiver Template

The Illinois Waiver form serves as a crucial application for individuals seeking employment in the health sector, particularly for those whose roles require direct patient care and have a history that might include criminal offenses. It is designed by the Illinois Department of Public Health and is essential for conducting a fingerprint-based criminal history records check, thereby ensuring the suitability of candidates for health care positions. For detailed instructions and to ensure a smooth application process, consider clicking the button below to fill out the Illinois Waiver form.

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Contents

In the bustling world of health care in Illinois, ensuring the safety and well-being of patients is a paramount concern. This rigor is reflected through the comprehensive process outlined by the Illinois Department of Public Health in the Health Care Worker Waiver Application. Aimed at health care professionals navigating their way through the complexities of employment in the state, this form serves as a crucial step for individuals who might otherwise be barred from employment due to past convictions. It meticulously collects personal data, from basic identification to detailed work history, and probes into any criminal background that might influence an individual’s suitability for health care work. Significantly, it underscores the importance of rehabilitation and redemption, allowing applicants to present proof of rehabilitation or compliance with probation conditions as part of their submission. The waiver application goes beyond a mere bureaucratic formality; it embodies a mechanism for vetting potential health care workers, ensuring they meet the high standards of care expected in Illinois. Moreover, the form is a gateway for many, offering a second chance to those who have made amends, demonstrating Illinois’ commitment to both public safety and individual recovery. The waiver not only acknowledges the complexity of human behavior and legal issues but also champions the idea that past mistakes should not indefinitely determine one’s professional future, especially for those aspiring to contribute meaningfully to the health care sector.

Illinois Waiver Sample

STATE OF ILLINOIS

Illinois Department of Public Health

HEALTH CARE WORKER WAIVER APPLICATION

Illinois Department of Public Health

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

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?				Yes	No	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?

Yes

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?

Yes

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?

Yes

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.

Signature

Date

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.

⇩ Illinois Waiver

Form Details

Fact Name	Description
Form Purpose	The Illinois Health Care Worker Waiver Application is designed to evaluate individuals seeking employment in health care settings for their suitability based on their criminal history.
Governing Law	The evaluation process is governed by the Health Care Worker Background Check Act (225 ILCS 46/25).
Required Identification	Applicants must provide detailed personal identification information including social security number, sex, race, height, eye color, and date of birth solely for identification purposes.
Authorization for Background Check	Applicants authorize the Illinois Department of Public Health and other specified entities to request and obtain their fingerprint-based criminal history records from the Illinois State Police and possibly the FBI.
Liability Waiver	The form includes a waiver of liability for any parties involved in the dissemination and use of the criminal history information obtained during this process, ensuring they cannot be held liable for carrying out their legal duties.
Special Considerations	Applicants must disclose any administrative findings of abuse, neglect, or theft, participation in rehabilitation programs if applicable, completion of probation or parole, and any fines paid related to disqualifying offenses.

Illinois Waiver - Usage Guidelines

Filling out the Illinois Waiver Form is a crucial step for health care workers in the state, especially those looking to secure employment. This process involves providing detailed personal information as well as consenting to a criminal history records check. The information collected is used solely for the purpose of identifying the applicant and evaluating their suitability for health care work. To ensure a smooth application process, it's important to follow the detailed steps below with care.

Start by entering Today’s Date at the top of the form.
Fill in your Name (First, Full Middle, and Last) in the designated field.
Provide your Address (Street, Apartment #, P.O. Box, City, State, ZIP Code).
List any Maiden Name or other name(s) used in the past.
Enter your Telephone number and Social Security Number (Note: Providing your Social Security Number is required by law).
Read and understand the authorization statement regarding the criminal history records check. By signing the form, you are consenting to this check.
Select your Sex, and fill in your Race, Height, Eye Color, and Date of Birth.
Complete the Work History section. If necessary, attach additional pages or a complete resume to provide a full employment history.
Answer the questions about previous offenses, including whether alcohol or drugs were involved, if you were ordered to participate in a rehabilitation program, or if you were required to pay a fine. Attach any required proof as necessary.
Indicate whether you have been certified as a nurse aide/assistant in another state and provide the relevant documentation.
Answer if you have ever had an administrative finding of abuse, neglect, or theft and provide details if applicable.

Provide information about any criminal offense convictions, other than minor traffic violations. Include details about the offenses, the state of conviction, and attach additional information if space is insufficient. Remember, do not include convictions that have been expunged, sealed, or were juvenile adjudications.

Optionally, you may submit a current or recent employment reference, a character reference, and other evidence demonstrating your competence and safety in health care work.

Sign and date the form to certify that all the information provided is true and correct. If the applicant is under 17, a parent or guardian must also sign and date the form.

Mail the completed form to the Illinois Department of Public Health, Health Care Worker Registry at the address provided at the top of the form.

After submitting your waiver application, the Department will process your information and send you a Livescan Request Form by return mail. This form is necessary for completing the fingerprint-based criminal history records check at one of the contracted Livescan vendors. Ensure you carefully follow all instructions provided with the Livescan Request to avoid any delays in your waiver application process.

Get Answers on Illinois Waiver

What is the purpose of the Illinois Health Care Worker Waiver Application?

The Illinois Health Care Worker Waiver Application allows individuals seeking employment in health care settings to request a waiver for certain disqualifications arising from their criminal history. Its aim is to ascertain the applicant's suitability for employment in health care roles, particularly when their past may include offenses that typically prevent such employment. Through this process, the state ensures that individuals are not unjustly barred from employment opportunities while maintaining the safety and integrity of health care services.

Who needs to complete the Illinois Health Care Worker Waiver Application?

Any individual who seeks employment in a health care setting within Illinois and has a criminal record that includes offenses that could disqualify them from such employment must complete the waiver application. This includes, but is not limited to, those applying for positions that involve direct patient care, access to patients, or access to patient information.

What information must be provided in the application?

The applicant must provide detailed personal information, including their name, address, Social Security Number, date of birth, race, eye color, and height. Additionally, the form requires details about the applicant's work history, any states other than Illinois where the applicant has lived or worked, information on any required rehabilitation programs, fines paid related to disqualifying offenses, probation or parole completion, nurse aide/assistant certification in other states, any administrative findings of abuse, neglect, or theft, and specifics regarding any criminal offenses.

Is it necessary to disclose all criminal offenses?

Yes, applicants must disclose all criminal offenses except for those that have been expunged, sealed, or were adjudicated in juvenile court. This includes providing detailed circumstances surrounding each offense, details of the conviction, and information on any rehabilitation or penalties associated with the offense.

What happens after submitting the application?

Upon submission, the Illinois Department of Public Health will review the application. If further action is required, such as a Livescan fingerprint check, the department will send a Liveslan Request Form to the applicant. Successful completion of this step and a satisfactory review of the application can lead to the waiver's approval, thereby allowing the applicant to pursue employment in health care settings despite their criminal history.

How does an applicant prove successful completion of a rehabilitation program?

An applicant must include proof of successful completion of any court-ordered rehabilitation program as part of the application. Acceptable proof can include certificates of completion, letters from the program director, or other official documentation that verifies the applicant completed the rehabilitation program as required.

What if an applicant is still paying fines related to a disqualifying offense?

If an applicant is on a payment schedule for fines related to a disqualifying offense, they must provide proof that they are up-to-date on their payments. Acceptable documentation includes receipts, payment records, or letters from the court indicating the payment status.

Can an applicant appeal if their waiver request is denied?

The application process includes provisions for appealing a denial of a waiver request. While the specifics of the appeals process can vary, generally, an applicant may be asked to provide additional information, undergo further review, or meet specific criteria to reconsider their application.

Who can an applicant contact for assistance with their Health Care Worker Waiver Application?

Applicants can contact the Illinois Department of Public Health for assistance through the contact information provided on the application. This includes a phone number (217-785-5133), fax number (217-524-0137), and email address (DPH.HCWR@Illinois.gov) for inquiries related to the application process.

Common mistakes

Filling out the Illinois Waiver form requires attention to detail and accuracy. Some common mistakes can lead to delays or even denial of the waiver application. Understanding these mistakes can help ensure a smooth application process.

Not providing complete information: Every section of the application must be filled out. Leaving out information, such as parts of your work history or failing to answer yes/no questions, can cause significant delays.

Illegible handwriting: If the form is not filled out online, it must be written clearly in ink. Hard-to-read handwriting can result in errors in processing the application.

Forgetting to attach necessary documentation: Documentation like proof of rehabilitation program completion, payment of fines, or proof of successful probation completion is crucial when applicable. Not attaching these documents can halt the application process.

Inaccurate criminal history information: All criminal offenses, excluding minor traffic violations, must be disclosed. Failure to provide accurate details or attempting to omit information can lead to denial.

Omitting information about employment or certification in other states: The application asks for a complete work history and whether you have been certified as a nurse aide/assistant in another state. Not providing full details or documentation can cause issues in verifying your qualifications.

Improper proof of name change: If you have changed your name due to marriage, divorce, or other reasons, legal documentation must be attached. Failing to do so can create confusion and delay the application process.

Understanding and avoiding these common mistakes can significantly improve the chances of a successful application process. It is always helpful to review all provided information and attached documents before submitting the form.

Documents used along the form

When dealing with the Illinois Waiver form, especially in the context of health care workers, it's often necessary to complement it with additional forms and documents to ensure compliance and thoroughness in the application process. The specific forms required can vary depending on individual circumstances, but there are a few that are frequently used alongside the waiver.

Employment History Verification: This document helps to verify the work history provided on the waiver application. It confirms past employment, dates of employment, and sometimes the reason for leaving, providing a clearer picture of the applicant’s professional background.
specialized services by the Department.
Criminal History Records Check: Required to support the waiver application, this document from the Illinois State Police or the Federal Bureau of Investigation outlines any criminal history of the applicant. It's essential for determining suitability for employment in a health care setting.

Proof of Rehabilitation: If the waiver application indicates a history of substance abuse, this document proves completion of a rehabilitation program. It's crucial for applicants who were ordered to undergo such programs as part of a judgment related to a disqualifying offense.

Certification or License Verification: For applicants who have held a professional license or certification in health care or related fields in other states, this document verifies that status. It’s necessary for those who claim to have such qualifications in their waiver application.

These additional documents play critical roles in the waiver application process. They provide necessary background checks, verify professional qualifications, and support claims made in the Illinois Waiver form. Collecting and preparing these documents carefully can help ensure a smoother application process for individuals looking to work in Illinois' health care industry.

Similar forms

The Illinois Waiver form is similar to other documents that also play a crucial role in the employment process, specifically within fields requiring a high degree of trust and integrity such as healthcare, education, and child care services. These documents typically serve to ensure that individuals are suitable for their roles, particularly when these roles involve vulnerable populations. Understanding these similarities helps in appreciating the importance and the context of the Illinois Waiver form within broader employment and regulatory processes.

Background Check Authorization Forms are closely related to the Illinois Waiver form in their purpose and content. Both forms require individuals to provide personal information and consent to a criminal history records check. The key similarity lies in their goal to safeguard vulnerable populations by ensuring that individuals with a history of offenses that could pose a risk are carefully evaluated before being employed. Like the Illinois Waiver form, they typically ask for detailed personal information—name, address, social security number—and explicit consent for the relevant authorities or organizations to conduct a criminal history check. However, while the Illinois Waiver form is specific to healthcare workers in Illinois, general background check authorization forms are used across various sectors and states.

Professional Licensing Application Forms share similarities with the Illinois Waiver form, especially in their function of regulation and safety assurance in specific professions. These forms are required for individuals seeking licensure in professions that have significant responsibilities and potential impacts on public welfare, including healthcare, law, and education. Like the Illinois Waicer form, professional licensing application forms often require the disclosure of personal information, criminal history, and other background details to assess the applicant's suitability and integrity for the profession. Moreover, they both may necessitate the submission of supplementary documents, such as proof of rehabilitation or professional qualifications, to support the application.

Employment Eligibility Verification Forms (I-9), while serving a different primary purpose from the Illinois Waiver form, also emphasize the importance of legal and regulatory compliance in employment processes. The I-9 form is used to verify the identity and legal authorization to work of all paid employees in the United States. Although it does not directly involve a criminal history check, it requires documentation and verification similar to the Illinois Waiver form, aiming to ensure that employees meet certain criteria essential for employment. This process underscores the broader employment framework's focus on safety, legality, and suitability, paralleling the objectives of the Illinois Waicer form in promoting a safe and compliant workforce.

Dos and Don'ts

When filling out the Illinois Waiver Form, especially for health care workers, following the right steps and avoiding common mistakes can aid in ensuring your application is processed smoothly. Here are essential dos and don'ts to consider:

Do type or print clearly in ink to ensure all information is legible.

Do provide all requested information comprehensively to avoid delays in your application being considered.

Do authorize the Illinois Department of Public Health and other specified entities to request a fingerprint-based criminal history records check as part of your application.

Do acknowledge the purpose of collecting personal information such as sex, race, height, eye color, and date of birth is purely for identification and processing of the waiver application.

Do include a complete work history or attach a resume as required, starting with your current employer.

Don't leave any section blank. If a section does not apply to you, indicate with an "N/A" (not applicable) to show that you have read and considered every part.

Don't forget to attach evidence of rehabilitation program completion if alcohol or drugs were involved in the offense you're seeking a waiver for.

Don't withhold information about past convictions, including those from other states or federal convictions, except for those that have been expunged, sealed, or were juvenile adjudications.

Don't include any identifying documentation (e.g., driver’s license, marriage certificate for name changes) unless you are providing information on a different name used when certified in another state or correcting your current name.

By addressing these points, you can help ensure that the review process of your Health Care Worker Waiver Application by the Illinois Department of Public Health is as straightforward and efficient as possible.

Misconceptions

There are several misconceptions surrounding the Illinois Health Care Worker Waiver Application that need to be clarified to ensure both applicants and employers have a proper understanding of the implications and requirements of the process. These misconceptions can impact an individual's application process and their employment opportunities in the health care industry.

Only criminal offenses disqualify applicants: It is a common misconception that only individuals with a criminal record are subject to disqualification. In reality, the application also inquires about administrative findings of abuse, neglect, or theft which can impact an applicant’s eligibility.

The waiver application process is instantaneous: Some may believe that the waiver process is quick and results are provided immediately. However, the process involves a comprehensive review, including a fingerprint-based criminal history check, which can take time.

Providing false information on the application carries no penalty: Falsifying information on the waiver application is a serious issue. Applicants must certify that the information provided is true and correct, and providing false information can lead to significant consequences, including legal penalties.

Any past offense will automatically disqualify an applicant: While certain offenses may disqualify an applicant, the waiver process exists to assess individual circumstances, rehabilitation efforts, and the nature of the offense. Not all offenses result in automatic disqualification.

Social Security numbers are optional: The application clearly states that providing a Social Security number is required by law. This information is necessary for the accurate processing of the criminal history records check.

Only Illinois criminal history is relevant: Applicants must disclose if they have been convicted of offenses in other states or have a federal conviction. The waiver application process considers criminal history beyond Illinois to ensure comprehensive background checks.

Personal references replace the need for a criminal history records check: Although applicants can submit personal and employment references, these do not replace the requirement for a fingerprint-based criminal history records check. References may support an application but do not exempt an applicant from background checks.

Rehabilitation efforts are not considered: The waiver application process takes into account whether an individual was ordered to participate in and successfully completed a rehabilitation program related to an offense. This information can be critical in the waiver decision-making process.

Understanding the complexities and requirements of the Illinois Health Care Worker Waiver Application process is crucial for all applicants. By dispelling these misconceptions, individuals can better prepare their applications and increase their employment prospects in the health care sector.

Key takeaways

Filling out the Illinois Waiver form accurately and comprehensively is crucial for health care workers seeking employment or looking to continue their employment in the health care sector. Here are key takeaways that one should remember when dealing with this form:

Every field in the application must be completed before consideration for a waiver will be entertained.

Applicants must type or print clearly in ink to ensure that all information is legible.

Providing a Social Security Number (SSN) is mandatory, as required by law.

The form includes authorization for the Illinois Department of Public Health and other designated bodies to request a fingerprint-based criminal history records check.

Applicants must acknowledge that they understand their employment may be affected by the results of a criminal history records check.

Information regarding sex, race, height, eye color, and date of birth is collected solely for identification purposes and not used discriminatorily.

A detailed work history or a complete resume is necessary, especially detailing any previous health care employment.

If involved in offenses related to alcohol or other drugs, evidence of participation and successful completion of rehabilitation programs must be presented.

Those who have been on probation, parole, or mandatory supervised release must provide proof of successful completion.

Applicants must disclose any past criminal convictions excluding minor traffic violations, expunged, sealed, or juvenile adjudications.

Supplementary documentation such as employment references, character references, or any other evidence demonstrating competency and safety in a health care environment can be submitted but is not mandatory.

The form concludes with a certification by the applicant that the information provided is true and correct, along with the consent for their name to appear on the Department’s Health Care Worker Registry alongside the results of their criminal history records check.

Minors under the age of 17 applying for this waiver must have a parent or guardian's consent for the criminal history records check.

The completed form should be mailed to the specified address of the Illinois Department of Public Health, Health Care Worker Registry.

Applicants will receive a Livescan Request Form by return mail, which they will use to have their fingerprints collected from a contracted livescan vendor.

Understanding and adhering to these guidelines can help ensure that the waiver application process is conducted smoothly and efficiently, ultimately aiding health care workers in their employment within the state of Illinois.

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