Appendix F Criminal Background Investigation (CBI) Application~1.pdf

This document is a Criminal Background Investigation (CBI) Application form from the New Jersey Department of Health and Senior Services for Certified Nurse Assistants, Personal Care Assistants, and Certified Assisted Living Administrators. The application outlines the mandatory process for obtaining criminal background checks required for certification in these healthcare positions. The document includes detailed instructions for completion, requirements for notarization, and specifies that processing takes at least 12 weeks.

The application includes a comprehensive list of disqualifying criminal offenses under various chapters of New Jersey state law, including crimes against persons, property crimes, and drug offenses. Applicants with prior convictions may request a determination of rehabilitation by submitting additional documentation including personal statements, proof of rehabilitation, and supporting documents. The form requires submission of personal information, screening questions regarding past criminal history, and must be submitted to the Criminal Investigation Unit in Trenton, NJ with a $1,000 fine possible for false statements. The application requires mandatory submission of Social Security Numbers under Privacy Act Notice PL 93-579 for criminal history coordination and child support enforcement compliance.