EMERGENCY MEDICAL TRAINING SERVICES
BACKGROUND CHECK
PLEASE ANSWER ALL QUESTIONS TRUTHFULLY. FAILURE TO REPORT AN OFFENSE WILL RESULT IN DISMISSAL FROM THE PARAMEDIC PROGRAM AND DISQUALIFICATION FROM RE-APPLYING. IF YOU ARE IN DOUBT AS TO WHETHER TO REPORT SOMETHING, REPORT IT. ADMISSION OF AN OFFENSE ON THIS FORM DOES NOT NECESSARILY MEAN DISQUALIFICATION FROM THE PROGRAM. FAILURE TO DISCLOSE DOES.
THE INFORMATION PROVIDED ON THIS FORM IS KEPT CONFIDENTIAL AND MAY ONLY BE RELEASED TO THE PROGRAM ADMINISTRATOR, PROGRAM COORDINATOR AND PROGRAM MEDICAL DIRECTOR. THE FOLLOWING MAY VIEW THE INFORMATION UPON WRITTEN REQUEST APPROVED BY THE PROGRAM ADMINISTRATOR; THE TEXAS DEPARTMENT OF HEALTH SERVICES AND CLINICAL/INTERNSHIP FACILITIES HUMAN RESOURCE/EDUCATION DEPARTMENT. THE INFORMATION PROVIDED WILL NOT BE DISCUSSED TO CURRENT, PRESENT OR FUTURE EMPLOYERS OR COMPANIES PERFORMING PRE-HIRE BACK GROUND CHECKS VERIFYING EDUCATION ACCOMPLISHMENTS AND STATUS WITHIN THE PROGRAM.
NAME: (Print full legal name)
________________________________________________________________
DRIVER’S LICENSE NUMBER AND STATE: _(_____)____________________
OTHER NAMES YOU HAVE USED IN THE LAST 10 YEARS:
(1)_____________________________________________________________________
(2)_____________________________________________________________________
CURRENT LEGAL ADDRESS:
Street/Apt#: __________________________________________________
City/County/State: _____________________________________________
NUMBER OF YEARS AT CURRENT ADDRESS: Years___________Months__________
PREVIOUS ADDRESSES FOR THE PAST 7 YEARS: Include dates at residence, city, state, and county.
DATES: _______________ Street: _______________________________________
City____________________ County_________________________ State___________
DATES: _______________ Street: _______________________________________
City____________________ County_________________________ State___________
DATES: _______________ Street: _______________________________________
City____________________ County_________________________ State___________
PLEASE CIRCLE YOUR RESPONSE
YES NO 1. Have you used illegal drugs even once in the last 10 years?
YES NO 2. Have you used prescription drugs which were not prescribed to you in the last 10 years?
YES NO 3. Have you supplied drugs, alcohol, or tobacco products to a minor, or assisted a minor in obtaining drugs, alcohol, or cigarettes in the last 10 years?
YES NO 4. Have you ever been charged with an offense of driving while under the influence of drugs or alcohol?
YES NO 5. Have you ever pled guilty or no contest to a charge of theft, assault, burglary, forgery or falsification of documents, manslaughter, or murder.
YES NO 6. Are you currently under a probationary sentence or deferred adjudication for any offense?
YES NO 7. Have you ever knowingly been in possession of stolen property or property which was obtained through fraud or forgery?
YES NO 8. Have you ever been convicted, plead guilty, plead no contest, or given deferred adjudication for ANY misdemeanor or felony?
IF YOU ANSWERED YES TO ANY OF THE ABOVE, PROVIDE DETAILS BELOW. INCLUDE DATE, COUNTY, AND STATE WHERE EVENT OCCURRED. LIST ALL CHARGES ABOVE A CLASS C MISDEMEANOR (traffic violation) AND THE OUTCOME OF THOSE CHARGES. IF THERE IS MORE THAN ONE CHARGE, LIST THEM STARTING WITH THE MOST CURRENT CHARGE. ATTACH AN ADDITIONAL SHEET OF PAPER IF NECESSARY.
I HAVE ANSWERED THE ABOVE QUESTIONS TRUTHFULLY TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE EMTS TO OBTAIN A CRIMINAL HISTORY, AND IN ACCORDANCE WITH THE FAIR CREDIT REPORTING ACT, TO RELEASE ANY INFORMATION OBTAINED TO THE CLINICAL AND INTERNSHIP AFFILIATES IF REQUESTED.
_______________________________________ _______________________________________
(Signature and date) (EMTS faculty witness signature)