Healthcare Worker Background Screening Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Employment Details
Job Title
Department / Facility
Start Date
Background Screening
Have you ever been convicted of a criminal offense?
No
Yes
If yes, please provide details
Professional License Number
License Expiry Date
Have you ever been subject to disciplinary action by a licensing authority?
No
Yes
If yes, please provide details
Declaration
I confirm that the above information is accurate to the best of my knowledge.
Date
Signature (Type full name)