Outline
The Illinois Waiver form is a crucial document for individuals seeking employment in the health care sector within the state. It is specifically designed for applicants who need to obtain a waiver from certain disqualifications related to their criminal history. The form requires comprehensive personal information, including the applicant's name, address, Social Security number, and contact details. Additionally, it includes sections for work history and any previous certifications as a nurse aide or assistant. Applicants must authorize background checks, which may involve fingerprinting, and provide details about any past criminal offenses. This process ensures that health care employers can verify the suitability of candidates while adhering to the regulations set forth by the Illinois Department of Public Health. The form also emphasizes the importance of providing accurate information and outlines the necessary documentation required for submission. By completing this form, individuals can take a significant step toward establishing their eligibility for employment in the health care field.
Sample - Illinois Waiver Form
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
All information requested on this application must be provided before you will be considered for a waiver. Type or print clearly in ink.
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Today’s Date |
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Name |
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(First, Full Middle and Last) |
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Address |
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(Street, Apartment #, P. O. Box) |
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(City, State, ZIP Code) |
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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
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 |
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Height |
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Eye Color |
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Date of Birth |
(Enter a letter from below): |
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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.
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Employer |
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Date Started |
Separation Date |
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Employer’s Address, City, State, ZIP Code |
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Employer |
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Date Started |
Separation Date |
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Employer’s Address, City, State, ZIP Code |
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Other states where you have lived or worked |
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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. |
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Were you required to pay a fine in connection to a disqualifying offense? |
Yes |
No |
If yes, you must provide |
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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
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 |
No |
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
No
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
No
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.
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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.
Form Information
| Fact Name | Fact Description |
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| Governing Law | The Illinois Waiver form is governed by the Health Care Worker Background Check Act (225 ILCS 46). |
| Purpose | This form is used to apply for a waiver from the Illinois Department of Public Health for health care workers. |
| Required Information | Applicants must provide personal information, including name, address, Social Security number, and work history. |
| Criminal Background Check | Applicants authorize a fingerprint-based criminal history records check as part of the application process. |
| Employment Considerations | Health care employers are not liable for hiring decisions based on criminal convictions as outlined in the Act. |
| Identification Information | Details like sex, race, height, eye color, and date of birth are collected solely for identification purposes. |
| Additional Documentation | Applicants may need to provide proof of rehabilitation or fines if applicable to their criminal history. |
| Submission Instructions | The completed form must be mailed to the Illinois Department of Public Health at the specified address. |
Detailed Guide for Filling Out Illinois Waiver
Completing the Illinois Waiver form involves providing accurate personal information and authorizations. After submitting the form, the Illinois Department of Public Health will process your application and send you a Livescan Request Form. This form is necessary for fingerprint collection through an approved vendor.
- Write the date on the top of the form.
- Fill in your full name, including your first name, middle name, and last name.
- Provide your complete address, including street, apartment number (if applicable), city, state, and ZIP code.
- Include your maiden name or any other names you have used.
- Enter your telephone number.
- Write your Social Security number, as it is required by law.
- Check the appropriate box to indicate your gender (Male or Female).
- Provide information about your race, height, eye color, and date of birth. Use the letter corresponding to your race from the list provided.
- List your entire work history, starting with your current employer. Include the employer's name, the date you started, the separation date, and the employer’s address.
- Indicate any other states where you have lived or worked.
- Answer the questions regarding alcohol or drug involvement in offenses, including whether you were ordered to participate in a rehabilitation program.
- Respond to questions about fines related to disqualifying offenses and provide proof if applicable.
- State whether you have been certified as a nurse aide/assistant in another state and attach necessary documentation if applicable.
- Indicate if you have had any administrative findings of abuse, neglect, or theft, and specify the state where this occurred.
- Answer whether you have ever been convicted of a criminal offense, providing details if applicable.
- Sign and date the form to certify that the information provided is true and correct.
- If applicable, a parent or guardian must sign and date the form for individuals under 17 years old.
- Mail the completed form to the specified address of the Illinois Department of Public Health.
Obtain Answers on Illinois Waiver
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What is the purpose of the Illinois Waiver form?
The Illinois Waiver form is primarily designed for individuals seeking employment in the healthcare sector. It allows applicants to request a waiver from certain disqualifications that may arise from their criminal history. By completing this form, candidates provide the Illinois Department of Public Health with essential information needed to assess their suitability for employment. This process ensures that healthcare workers meet the necessary standards for safety and competency in their roles.
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What information is required to complete the form?
To successfully complete the Illinois Waiver form, applicants must provide a range of personal information. This includes:
- Full name, including maiden name if applicable
- Current address and contact details
- Social Security number (mandatory)
- Details about past employment, including work history and any relevant certifications
- Information regarding any criminal offenses, including specifics about the circumstances and outcomes
All sections must be filled out clearly and accurately to ensure a smooth review process.
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How does the criminal history check process work?
Once the Illinois Waiver form is submitted, the Illinois Department of Public Health will initiate a fingerprint-based criminal history records check. This check is vital for determining whether the applicant has any disqualifying offenses. The applicant must authorize this background check, which may involve coordination with the Illinois State Police and other relevant agencies. After the form is processed, the department will send a Livescan Request Form, which the applicant will use to have their fingerprints taken at an authorized vendor.
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What happens if I have a disqualifying offense?
If an applicant has a disqualifying offense, they may still be eligible for employment depending on various factors, such as the nature of the offense and the time elapsed since it occurred. The waiver application allows individuals to explain their circumstances and provide supporting documentation, such as proof of rehabilitation or completion of any required programs. The Illinois Department of Public Health will review these details carefully to make an informed decision regarding the waiver request.
Common mistakes
Completing the Illinois Waiver form can be a straightforward process, but many individuals make critical mistakes that can delay or derail their applications. One common error is failing to provide complete and accurate personal information. The form requires essential details such as your full name, address, and Social Security number. Omitting any of this information can lead to significant delays. It is vital to double-check that all fields are filled out correctly before submitting the application.
Another frequent mistake involves the work history section. Applicants often do not include a comprehensive account of their previous employment or fail to attach a complete resume. The form specifically states that you must provide a full work history starting with your current employer. Neglecting this requirement can result in the denial of your waiver, as the Illinois Department of Public Health needs this information to assess your eligibility.
Additionally, many applicants overlook the need to provide supporting documentation for any criminal offenses. If you have been convicted of a crime, the form requires a detailed account of the circumstances surrounding each offense. This includes the state of conviction and any rehabilitation programs you may have completed. Failure to provide this information, or to include proof of completion for any required rehabilitation, can jeopardize your application.
Finally, individuals often forget to sign and date the form before submitting it. This step may seem trivial, but without your signature, the application will be considered incomplete. It is essential to ensure that all required signatures are present, including those from parents or guardians if the applicant is under 17. Taking these precautions can help ensure a smoother application process and increase the chances of approval.
Documents used along the form
When applying for a waiver in Illinois, several additional forms and documents may be necessary to support your application. Each of these documents plays a crucial role in ensuring a thorough review of your background and qualifications. Below are some common forms that often accompany the Illinois Waiver form.
- Livescan Request Form: This form is sent by the Illinois Department of Public Health after you submit your waiver application. It is essential for scheduling a fingerprinting appointment with a contracted vendor. The results of this fingerprinting will help verify your criminal history.
- Employment Reference Letter: While not mandatory, this letter can strengthen your application. It typically includes a statement from a previous employer regarding your work ethic, skills, and suitability for the health care field.
- Character Reference Letter: Similar to the employment reference, this letter should come from someone who can vouch for your character. It may be from a community leader, mentor, or someone familiar with your professional conduct.
- Proof of Rehabilitation: If you have had any past offenses, documentation showing successful completion of a rehabilitation program is important. This proof demonstrates your commitment to personal growth and responsibility.
Gathering these documents can be a vital step in the waiver application process. By providing comprehensive and accurate information, you enhance your chances of a favorable outcome. Always ensure that you keep copies of everything you submit, as this can help you track your application status and respond to any follow-up requests efficiently.
Similar forms
The Illinois Waiver form shares similarities with several other documents that are often used in various applications and consent processes. Here’s a list of seven documents that are comparable:
- Background Check Authorization Form: Like the Illinois Waiver, this form allows an employer to conduct a background check on an applicant, ensuring they meet the necessary qualifications for employment.
- Criminal History Release Form: This document permits law enforcement agencies to release an individual's criminal history to employers or other entities, similar to the authorization in the Illinois Waiver.
- Employment Application: An employment application gathers personal information, work history, and qualifications, much like the information requested in the Illinois Waiver.
- Health Care Worker Registry Application: This application is specifically for health care workers to register and may require similar personal and background information as the Illinois Waiver.
- Fingerprint Consent Form: This form is used to consent to fingerprinting for background checks, paralleling the fingerprint-based checks mentioned in the Illinois Waiver.
- Release of Information Form: This document allows third parties to access personal information for verification purposes, akin to the information release in the Illinois Waiver.
- Certification Application: This application is used by individuals seeking certification in various professions and often requires personal information and background checks, similar to the requirements of the Illinois Waiver.
Dos and Don'ts
When completing the Illinois Waiver form, attention to detail is crucial. Here are some important guidelines to follow:
- Do: Provide all requested information accurately and completely.
- Do: Type or print clearly in ink to ensure legibility.
- Do: Include your Social Security number, as it is required by law.
- Do: Attach any necessary documentation, such as proof of rehabilitation or name change.
- Do: Review your work history thoroughly before submission.
- Don't: Leave any sections blank; all information is essential for processing.
- Don't: Provide false information; honesty is vital in this application.
- Don't: Forget to sign and date the form; your signature is necessary for consent.
- Don't: Submit the form without making copies for your records.
Misconceptions
Here are seven common misconceptions about the Illinois Waiver form:
- All information is optional. Many believe that they can skip questions on the form. In reality, all requested information must be provided for the waiver to be considered.
- Only certain criminal records are checked. Some think only serious offenses are reviewed. However, the form allows for a complete background check, including all criminal history, not just major crimes.
- The waiver guarantees employment. Some applicants assume that completing the waiver will automatically lead to a job. This is not true; the waiver simply allows for consideration based on background checks.
- Providing a Social Security number is optional. Many individuals think they can leave this out. In fact, providing a Social Security number is required by law for the waiver process.
- The form is only for healthcare workers with criminal records. Some believe that only those with a criminal history need to apply. However, anyone seeking employment in healthcare must complete the waiver.
- Submitting the form is the final step. Many think that once they send in the waiver, they are done. In reality, additional steps, such as fingerprinting, are required after submission.
- All submitted documents will be returned. Some applicants expect their additional materials, like references, to be sent back. However, the form states that submitted materials will not be returned.
Key takeaways
When filling out and using the Illinois Waiver form, it is important to follow specific guidelines to ensure your application is processed smoothly. Here are some key takeaways:
- Complete All Sections: Provide all requested information clearly. Incomplete applications may delay processing.
- Authorization for Background Check: You must authorize the Illinois Department of Public Health to conduct a fingerprint-based criminal history check.
- Social Security Number: This number is required by law and must be included on the form.
- Work History: An entire work history must be provided, starting with your current employer. Attach additional pages if necessary.
- Proof of Rehabilitation: If applicable, include proof of successful completion of any required rehabilitation program.
- Legal Documents: If your name has changed, provide legal documentation such as a marriage certificate or divorce decree.
- Criminal Offenses: Disclose any criminal offenses, including details about the circumstances and the state of conviction.
- References: Although not required, submitting a current employment reference or character reference can support your application.
- Mailing Instructions: Send the completed form to the specified address to initiate the processing of your waiver application.
Following these guidelines can help facilitate a smoother application process and increase the likelihood of a favorable outcome.