Form 1725, Criminal Conviction History and Registry Checks

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Documents

Effective Date: 3/2023

Instructions

Updated: 9/2015

Purpose

To document:

  • an applicant's authorization for a required criminal conviction history check to be conducted by the Financial Management Services Agency (FMSA);
  • an applicant's authorization for required registry checks to be conducted by the FMSA;
  • the applicant's personal information required to make the checks;
  • an employer certification regarding confidentially of criminal history reports;
  • the results of the checks; and
  • the applicant's eligibility to be employed, retained as an independent contractor or as a vendor.

For the purpose of this form, an applicant is a person applying for a position as a service provider (employee, independent contractor or, if required, a vendor).

Procedure

When to Prepare

This form must be completed before a service provider applicant can be hired or retained by the Consumer Directed Services (CDS) employer.

Number of Copies

Original and one copy.

Transmittal

The FMSA keeps the original or a copy and sends the original or a copy to the employer.

Form Retention

The employer and the FMSA must keep this form, for five years after termination of the service provider, or until all outstanding litigation, claims and audits are resolved.

DETAILED INSTRUCTIONS

Section I – Applicant Authorization/Acknowledgment

The applicant must complete this section.

The applicant must print his/her name, sign and date the form to authorize the FMSA to conduct a criminal conviction history and the employer or the FMSA to conduct a registry check.

Applicant Information Required by the Texas Department of Public Safety (DPS)

The applicant must complete this section.

Section II – Criminal Conviction History Check and Registry Verification Process

The employer must complete this section.

Individual's Name — Enter the name of the person receiving services.

Employer Name — Enter the name of the employer.

Employer Acknowledgment of Request and Certification of Confidentiality of Criminal History Record Information — Employer checks each box to show understanding.

Signature – Employer/Date — The employer must sign and date.

Employer Acknowledgment of Request of Registry Check — Employer checks each box to show understanding.

Signature – Employer/Date — The employer must sign and date.

Section III – Criminal History and Registry Check Results

DPS Criminal History Check

  • Only the FMSA may document the results on this form. The FMSA sends the completed form to the employer.
  • The Criminal History Check must be current – no more than 30 days before the date of hire.
  • A person who works for an employer on a seasonal basis every year does not need another criminal background check, unless the employer requests one.
  • A person who previously has been employed or retained by the employer and is being re-hired or will be retained again by the employer, must have a current DPS Criminal History Check (no more than 30 days before the date of hire).
  • FMSA Dissemination Method: The FMSA checks the method used to share secure DPS information with the CDS employer. (Only the original report can be disseminated. Copies of the report are not allowed to be made and disseminated.)

Date of DPS Check — Enter the date the results were received from DPS as noted in the report.

Time — Enter the time the results were received from DPS as noted in the report, and check the box for either AM or PM.

Obtained by — Enter the name of the FMSA representative who obtained the results.

Convictions — Check yes if there were any criminal convictions barring employment. (If yes, does the conviction(s) ...) If yes is checked, complete the following section. Check no if no criminal convictions were listed.

If yes, does the conviction(s) prohibit service delivery or serving as a DR in compliance ... — Refer to Appendix I, Criminal Convictions Barring Employment, in the Consumer Directed Services Handbook for a list of criminal convictions that prohibit employment, and mark this item appropriately. Check yes if there are any criminal convictions that bar employment. Check no if there are any criminal convictions that do not bar employment. If yes is checked, the applicant must not be hired or retained as a provider.

Registry Checks — Only the employer or the FMSA may obtain the required registry checks. If a person who previously has been employed or retained by the employer is being re-hired or will be retained again by the employer, the required registry checks must be obtained for that individual.

  • If the FMSA completes the registry checks, the FMSA must send the original or a copy of the completed form to the employer.
  • If the employer completes the registry checks, the employer must send the original or a copy of the completed form to the FMSA.

Date of Registry Results — Enter the date the registry check results were obtained (this date must be no more than 30 days before the initial date the applicant will provide services or serve as a DR).

Time — Enter the time the registry check results were obtained and check the box for either AM or PM.

Obtained by — Enter the name of the individual who obtained the registry check results and check the appropriate box to indicate whether he or she is the employer or the FMSA representative. If the applicant is designated in either registry as having abused, neglected or exploited a resident or individual of a facility or misappropriated a resident's or individual's property, then check Record. The applicant must not be hired or retained as a service provider. If the applicant has not been designated in either registry as having committed any of the actions noted above, then check No Record.

Certification

The FMSA representative must sign and date the form certifying that the checks were performed and the results were shared with the CDS employer.

Note: See Appendix I, Criminal Convictions Barring Employment, in the Consumer Directed Services Handbook.