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CVJ STATE OF MINNESOTA DEPARTMENT OF HUMAN SERVICESPRIVACY NOTICEBocaii»e litis fuiiii roiiuusts that pruvido privato infor­mation. tlio Minnesot.i GovrrnmnnI Data Practicos Act reiiuitos lltal you be inloiniod of the fulluwinyV-r--. / <br />n <br />¥ <br />¥ <br />¥ <br />¥ <br />¥ <br />¥ <br />¥ <br />¥ <br />Purpote and intended u*e of the information; <br />Minnesota Statues, chapter 24f>A. and Minnesota Rule <br />1 1 leiiimo the Department of Human Services (OHS) <br />to pel form bacKyiound studies of indivitluals woikiny <br />to positions atlowiny direct contact with persons re- <br />cotviny services from proyrarns liconsod by OHS The <br />reyuested information will be used to perform a back- <br />ground study of you that will include, but will not be <br />limited to, a review of criminal conviction records held <br />by the Bureau of Criminal Apprehension and cases of <br />substantiated abuse and neylect of vulnetuble adults <br />and niallreatnui'it of inuiors <br />UJ <br />->J <br />£X <br />>c <br />UJ <br />Whether you may refuse or ; re legally required to <br />|irovide the information: Hie above cited statute and <br />rule require that all individuals working m positions <br />dllowimj direct contact with persons receiving services <br />bom pruqrams liccosad by OHS provide sufficient in- <br />fufiiialiun to ensure an accurate study <br />Known consequences that may arise from supplying <br />the information: Inilivuluals I whom no history of <br />disqualdymy charactcMistics are discovered will not be <br />disqualified, while individuals who are found to have <br />histones with particular cliaiacteiistics. es Klenidied in <br />Rule 1 1. may be disqualified <br />Known ciMisequences that will arise from refusing <br />In supply the requested information. Only .ue itenis <br />irlentilied as ‘optional** may be left blank lr.cr<mplete <br />furnis will be returned to the facility, and rna\ alfect <br />tlie facilily s ability to employ you •'* a poi..tK»n allowing <br />direct contact with persons receiving services Hefusal <br />to provHte tl*e information necessary to ensure an <br />accurate bacKyrufiul study wdl result in diiqualificalion <br />iderilificetion of other agencies or entities authoris ­ <br />ed to recetva this information lo perform the ba* k- <br />ground study, the info'matKKi you provide will be <br />sliared with the BCA If the commissi • ser has feasonaWe <br />cause to bebeve that other agencies may have inf or • <br />ruatiun pertinent to disquahfication. the mforination <br />you gnre may also he shared with county attoineys. <br />county slieriffs. courts, county egeiKries. local police, <br />the nationel recwd lepository . criminal recoids infor­ <br />mation systems in oilier states and pivenile c out is llie <br />infiumatKin about you received as part of the hack- <br />giOMiHj study is classified as private informalnm and <br />can not be released to anyone witlHHil your wiiHen <br />consent If you ere found to have a disqualifying <br />r.haiactenstic. your emfiloyer will be io4d only that you <br />ere chsqoelified and wU not be tuki what the mforrna- <br />lion was that caused your iieqyaef«calM <br />DIVISION OF LICENSINGBACKGROUND STUDY FORMINSTRUCTIONSTo complete tins tu.m. pU>..so use a *2 pencil end completely f.H in the appropriate bul.Dle under each ch.iracter you write Pnotucopie. orms can no he processed and will he leiurncd to the license liolder Folded forms can not he processed electronically, and may cause a delay Aftr r cninpletiiuj bothsKles <br />of this torm. send ilio compfoted form to: <br />Department of Human Services <br />Applicant Backyroui j Study Unit <br />Division of licensiny <br />444 Lafayette Road <br />St Paul. 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