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Demographic Information

Employment Desired

Healthcare Worker Background Check

I understand that the information requested below regarding date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it 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.

The Health Care Worker Background Check Act requires health care employers to conduct Illinois State Police criminal history record checks on employees who have responsibility for direct care and who are not otherwise licensed by the Illinois Department of Professional Regulation or the Department of Public Health. In long-term care facilities, the law primarily applies to certified nurse aides. As the result of criminal history record checks, persons with disqualifying convictions in any of 28 areas may not work in a position having direct care responsibilities without a waiver issued by the Department.


Please furnish name and phone number of three personal references. These individuals should not be previous employers or relatives.

Educational Background

Include where training occurred and type of certification if applicable.

Include specific duties, locations and dates.

Employment Experience

Begin with your present or most recent job. Include military service assignments and internships.

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By typing my name, I verify that the information contained on this application is correct. I understand that falsifying any portion of this application is grounds for termination.

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