Fingerprint Request Form I9.pdf
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About this file
This is an appendix containing required forms and criteria for personnel background screening at the Nebraska-Western Iowa VA Healthcare System (NWIHCS).
The first component is the NWIHCS VA Police Service Fingerprint Request Form, which collects personal identification information including name, Social Security number, date of birth, physical descriptors, citizenship status, and employment affiliation. The form categorizes individuals by VA employment status (full-time employee, part-time employee, without compensation, affiliating trainee, affiliating faculty, or contract employee) and identifies whether the assignment exceeds 120 days, whether the individual provides direct patient care, and whether computer access is required. Fingerprinting services are conducted in Omaha and Lincoln on a walk-in basis Monday through Friday from 8:00 a.m. to 11:30 a.m. and noon to 4:00 p.m. in Main Hospital Room B804. Contractor personnel must submit completed forms to the Contracting office at Building C, Room 101 for Omaha and Lincoln facilities, or to Human Resources for the Grand Island facility. The form includes privacy and confidentiality notices regarding information access and the Privacy Act requirements.
The second component establishes PIV Identity Documentation Criteria specifying that two forms of identification are required—either two forms from the left column (Federal or State Government issued picture ID) or one form from the left column combined with one non-picture ID from the right column. Identification documents must not be expired except for U.S. Passports, and VA PIV Cards are acceptable as federally issued identification. Handwritten or photocopied documents are not accepted. The criteria also address legal name changes and require that applicant names on the VA PIV Registration Portal must match the name on presented identification documents.
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Text version
01 00 00 – Appendix B
01 00 00 - Appendix B - 1 of 2
NWIHCS VA POLICE SERVICE
FINGERPRINT REQUEST FORM
NAME (Last, First, Middle):
SOCIAL SECURITY NUMBER:
DATE OF BIRTH (YEAR/MONTH/DAY):
ALIAS (MAIDEN NAME):
GENDER: RACE/ETHNIC BACKGROUND:
EYE COLOR: HAIR COLOR:
HEIGHT: Feet: Inch: WEIGHT: Lbs:
PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
CURRENT STREET ADDRESS:
CITY, STATE, POSTAL CODE:
CITIZENSHIP:
OCCUPATION:
EMPLOYER / SCHOOL AFFILIATION
AGENCY USE ONLY BELOW THIS LINE
TO BE COMPLETED BY HUMAN RESOURCES OR SPONSORING SERVICE
INDIVIDUAL’S VA STATUS:
FULL TIME VA EMPLOYEE PART TIME VA EMPLOYEE WITH OUT COMPENSATION (WOC)
AFFILIATING TRAINEE (STUDENT) AFFILIATING FACULTY CONTRACT EMPLOYEE
ASSIGNMENT OVER 120 DAYS YES NO
PROVIDES DIRECT PATIENT CARE YES NO
COMPUTER ACCESS REQUIRED YES NO
VA POLICE USE ONLY
IDENTITY VERIFICATION
DRIVERS LICENSE NUMBER: STATE OF ISSUE:
OR
PASSPORT NUMBER: COUNTRY OF ORIGIN:
FINGERPRINTS CONDUCTED BY: DATE COMPLETED:
The VA Police conducts fingerprinting in Omaha and Lincoln. Fingerprinting in Omaha is on a walk in basis Mondays-Fridays from 8:00 – 11:30 a.m. and Noon – 4:00 p.m. in the Main Hospital Room B804. For assistance or questions please call 995-5818.
CONTRACTOR PERSONNEL: FOR THE OMAHA AND LINCOLN FACILITIES SEND THE COMPLETED FORM TO CONTRACTING AT Building C, Room 101. FOR THE GRAND ISLAND FACILITY SEND THE COMPLETED FORM TO HR.
NOTICE: Access to this information is limited to AUTHORIZED PERSONS ONLY. Information may not be disclosed from this document unless permitted pursuant to 38 CFR 1.500 – 1.599. These records may not be altered or destroyed except as authorized by 38 CFR 1.579. This transmission is intended only for the use of the person or office to whom it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that receipt of this message does not waive any applicable privilege or exemption from disclosure and that any dissemination, distribution, or copying of this communication is prohibited. VA follows the requirements of the Privacy Act, which protects your personal information that VA maintains in “systems of records”. If you have received this communication in error, please notify us immediately at the telephone number shown above. Thank you.
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01 00 00 – Appendix B
01 00 00 - Appendix B - 2 of 2
- - - END OF SECTION 01 00 00 - - -
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