KU

MASTER OF SCIENCE IN PHYSICIAN ASSISTANTS PROGRAM
BACKGROUND CHECK INFORMATION AND RELEASE FORM

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The Joint Commission on Accreditation of Health Care Organizations (JCAHO) has implemented requirements for criminal background checks. Standard HR. 1.20 for staff, students and volunteers who work in the same capacity as staff who provide care, treatment, and services at EP 5 states criminal background checks are verified when required by law and regulation and organization policy. (www.jcaho.com)

State and/or federal laws through designated agencies regulate health professions. Each agency sets the specific requirement for granting licensure or certification to practice as a healthcare provider. Most agencies have restrictions on eligibility to sit for credentialing examinations and granting licensure or certification to an individual with a criminal record and/or suspension of a professional license.

I have read the above statement and understand that as part enrollment process it is necessary for me to disclose the following information and have a background check completed bt the University:

  • Have you ever been convicted of a misdemeanor or felony? Yes No
  • Have you ever had a professional license suspended or revoked? Yes No

Note: Convictions or charges resulting in any of the following must also be reported.

  • Plea of guilty Yes No
  • Plea of nolo contendere (no contest) Yes No
  • Withheld or deferred adjudication Yes No
  • Suspended or stay of sentence Yes No
  • Military court martial Yes No

By my signature I attest to having answered the following questions truthfully.


Name/Electronic Signature By typing your name you have created an electronic signature as legally binding as your handwritten signature.