Healthcare Contractor Background Screening Form
Full Name
Date of Birth
Current Address
City
State
ZIP Code
Phone Number
Email Address
Contractor Company Name
Position/Role
Proposed Start Date
Professional License(s) (if applicable)
Have you ever been convicted of a crime?
No
Yes
If yes, please provide details
Have you undergone a background screening in the past year?
No
Yes
I authorize the healthcare facility to conduct a background screening check.