1-Background Check Form.pdf

X X

FOR INTERNAL USE ONLY

HR Clearance:

2.4 HR clear date:

2.5 Number of exceptions noted by HR:

BACKGROUND CHECK FORM

Sec. 1: Project Sponsor Details. To Be Completed after Submissions

(FOR INTERNAL USE ONLY)

Name:

Phone #:

E-Mail:

Department:

Project Start Date:

Project End Date:

Vendor MUST complete Sec. 2. If there will be no direct contact with students, check the "NO" box and sign the form.

Sec. 2: Vendor Details

2.1 Vendor Name:

2.2 Will Vendor have direct contact with students? Yes No

*Contact that results from activities that provide substantial opportunity for verbal or physical interaction with students and that is NOT supervised by a certified educator or other professional district employee.

2.3 Is Vendor NCPA qualified? Yes No

*Under the National Child Protection Act (NCPA) only qualified businesses and organizations that provide care or placement services for the care, treatment, education, training, instruction, supervision or recreation to children, the elderly, or individuals with disabilities can become a qualified entity under NCPA and will not require background check conducted by

FBISD.

Sec. 3: Contract Worker Details

First Name Middle Name Last Name DOB DL# DL State Abb

*Attach additional pages as necessary

Name & Title of Authorized Representative Signature of Authorized Representative