2016 Version EHS DCS CORI Form 07 2015.docx
DOCX document 52 KB Posted
- Solicitation number
- BD-15-1067-MCD01-MCD01-00000003934
- Issued by
- Suffolk County, Massachusetts
About this file
This document is a CORI Request Form for the Commonwealth of Massachusetts Executive Office of Health and Human Services Disabilities and Community Services Office of Human Resources. The form is used to obtain criminal offender record information (CORI) on applicants/employees for positions within the agency. The CORI information will be reviewed by qualified mental health professionals to determine if the applicant poses an unacceptable risk of harm to the agency's clients. The form collects standard applicant information such as name, date of birth, Social Security number, and government-issued identification.
The document is related to a state and local contract opportunity for the Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH) to renew their MCD01 Contract for Interpreters and Transliterators for the Deaf and Hard of Hearing for the FY'16 to FY'18 term. This contract provides interpreter services for MCDHH program participants. The contract term is three years with potential renewal options.
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Text version
AGENCY CODE: EOHHD
FEE CODE:
Commonwealth of Massachusetts Executive Office of Health and Human Services Disabilities and Community Services Office of Human Resources 600 Washington Street
Boston
MA
02111
MARYLOU SUDDERS
Secretary
CHARLES D. BAKER
Governor
KARYN POLITO
Lieutenant Governor
CORI REQUEST FORM
NOTICE TO FINAL CANDIDATES
In the event that a CORI investigation returns a record with a criminal history that is relevant to the duties of the position being sought, the CORI results may be utilized by a qualified mental health professional in order to make a determination regarding whether or not the candidate poses an unacceptable risk of harm to the clients of the agency, in accordance with 101 DMR 15.09.
The Executive Office of Health and Human Services has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for the position of , I understand that a criminal offender record information (CORI) check will be conducted for conviction and pending criminal case information only and that such information will not necessarily disqualify me. The information below is correct to the best of my knowledge.
APPLICANT/EMPLOYEE SIGNATURE
(Unless otherwise preempted by law)
APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT)
| LAST NAME | FIRST NAME | MIDDLE NAME |
| MAIDEN NAME OR ALIAS (IF APPLICABLE) | PLACE OF BIRTH |
| - - | ||
| DATE OF BIRTH | SOCIAL SECURITY NUMBER | ID Theft Index PIN (if applicable)* |
MOTHER’S MAIDEN NAME
CURRENT AND FORMER ADDRESSES:
SEX: HEIGHT: ft. in. WEIGHT: EYE COLOR:
STATE DRIVER’S LICENSE NUMBER:
(include state of issue)
THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION:
(Attach COPY of PHOTO ID)
REVIEWED BY:
Signature-SUPERVISOR/MANAGER REVIEWING IDENTIFICATION
REQUESTED BY:
SIGNATURE OF CORI AUTHORIZED EMPLOYEE
*The CHSB Identity Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the CORI request process. All CORI request forms that include this field are required to be submitted to the CHSB via mail or by fax to 617-660-4614 image1.wmf oleObject1.bin
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