UP Nursing: Background Check

UNIVERSITY OF PORTLAND SCHOOL OF NURSING
CONVICTION/CRIMINAL HISTORY INFORMATION

When considering student for school enrollment and faculty for employment , conviction/criminal history records are reviewed as they relate to the content and nature of the curriculum and the safety and security of patients and the public. Additionally, we require that students and faculty disclose specific information about any convictions for crimes against persons and crimes relating to financial exploitation and findings in related actions and proceedings. This conviction information must be disclosed before faculty appointment and before a student can be considered for enrollment in any nursing degree program which may involve unsupervised access to children, developmentally disabled persons or vulnerable adults as defined by the law. A conviction/criminal history record does not necessarily disqualify an individual for admission or employment. Criminal history records may be verified through law enforcement related agencies; initial and/or continued enrollment or employment may be subject to a satisfactory Criminal Conviction Report. . Students and faculty must agree to sign the release form or will be removed from consideration for enrollment or employment. The School of Nursing will not place students or faculty in clinical facilities without a criminal history check. A Social Security number is a required part of your application. It is a unique identifier necessary to conduct the criminal history background check required of all applicants.

Last Name	First Name	Middle Name
Email Address
Zip Codes of All Current and Prevous Residence since 18 years of age (separate by space)

Social Security Number

Choose One:
Graduate
Undergraduate
Faculty

Other Last Names You Have Used

Date of Birth (CCYY-MM-DD)

1. CRIMES AGAINST PERSONS AND CRIMES RELATING TO FINANCIAL EXPLOITATION:
Have you ever been convicted of any of the crimes listed below?

Yes No If Yes, check all that apply and Part 5 provides further instructions.
Arson (1st degree)	Custodial Interference (1st/2nd Degree)	Promoting Prostitution (1st Degree)
Assault, Custodial	Extortion (1st/2nd/3rd* Degree) Forgery *	Prostitution
Assault, Simple (or 4th Degree Assault)	Incest	Robbery (1st/2nd Degree)
Assault (1st/2nd/3rd Degree)	Indecent Exposure - Felony	Rape (1st/2nd/3rd Degree)
Assault of a Child (1st/2nd/3rd Degree)	Indecent Liberties Kidnapping	Rape of a Child (1st/2nd/3rd Degree)
Burglary (1st Degree)	(1st/2nd Degree) Malicious	Selling/Distributing Erotic Material to a Minor
Child Abandonment	Harassment	Sexual Exploitation of a Minor
Child Abuse or Neglect	Manslaughter (1st/2nd Degree)	Sexual Misconduct with a Minor (1st/2nd Degree)
Child Buying or Selling	Murder, Aggravated	Theft (1st/2nd/3rd* Degree)
Child Molestation (1st,2nd,3rd Degree)	Murder (1st/2nd Degree)	Unlawful Imprisonment
Communication with a Minor	Patronizing a Juvenile Prostitute	Vehicular Homicide
Criminal Abandonment	Promoting Pornography	Violation of Child Abuse Restraining Order
Criminal Mistreatment (1st/2nd Degree)

2. DRUG-RELATED CRIMES

Yes No

Have you ever been convicted of a crime related to the manufacture of, delivery of, or possession with intent to manufacture or deliver a controlled substance?

3. RELATED PROCEEDINGS

Yes No

Have you ever been found in a dependency action, domestic relations proceeding, disciplinary board hearing, or protection proceeding to have: sexually assaulted or exploited, sexually or abused physically, a minor or developmentally disabled person OR to have financially exploited or abused a vulnerable adult?

4. MEDICARE-MEDICAID/HEALTHCARE RELATED CRIMES

Yes No	Have you ever been convicted of any crime related to the delivery of service under Medicare/Medicaid or any state or federal healthcare program, or convicted of any crime connected with the delivery of a healthcare item or service?
Yes No	Have you ever been judged liable for civil monetary penalties for conduct related to the delivery of services, supplies or other participation in Medicare/Medicaid or any other state or federal healthcare program?
Yes No	Have you ever been excluded from providing services or supplies under Medicare, Medicaid or any other federal funded healthcare program?

5. For all items checked in 1, 2, 3 and 4 above, specify the conviction or action date(s), sentence(s) or penalty(ies) imposed, prison release date(s) and current standing (e.g., parole, work release). For all items with an asterisk (*) above, provide a description of the victim including the victim's age.

6. GENERAL CONVICTION INFORMATION:
Aside from those crimes listed above, within the past 10 years have you ever been convicted of or released from prison for any crimes, excluding parking tickets/traffic citations?

Yes No

If Yes, indicate all conviction dates, prison release date(s) and the nature of the offense(s)

7. RESIDENCY:
If you have resided outside of the state of Oregon over the past seven years you must have an official criminal history background check from EACH STATE in which you resided. Please respond to the following:

Yes No	1. Have you lived outside the State of Oregon in the past seven years? Please list each city (please provide county name) and state in which you have lived over the past seven years:

Under penalty of perjury, I certify that the above-stated information is true, correct and complete. I understand that I can be dismissed from the program for any misrepresentation or omission in the above-stated information. I understand that the University of Portland may verify this information through the Oregon State Police or other law enforcement related agency. I also understand that enrollment or employment may be conditioned on the University’s receipt of a satisfactory Criminal Conviction Report from the Oregon State Police, other law enforcement related agencies, using both national and local databases

Authorization for Repeat Background Checks and Dissemination of Results
I agree to a repeat background checks, and dissemination of my self-disclosure information, background check results, and conviction records to clinical training sites, whether in or outside the State of Oregon, as deemed necessary by the School of Nursing, during the completion of my academic program. I understand that the University of Portland will provide the records listed above only with the condition that the receiving party or parties will be notified by the University that they may not disclose the information to other parties, in a personally-identifiable form, without my further consent, unless the other parties are otherwise eligible under federal or state law to receive the records. I further understand that any statements that I have placed in my records commenting on contested information contained in the records listed above will be released along with the records to which they relate.

Signature Date (MM/DD/CCYY)