Article Guide
The Illinois Waiver form is an essential document for individuals seeking employment in the health care sector within the state. This form facilitates the process of obtaining a waiver from certain disqualifications that may arise due to past criminal offenses or other issues. Applicants must provide detailed personal information, including their name, address, and Social Security number. Additionally, the form requires a comprehensive work history and questions about any previous criminal convictions, rehabilitation programs, or administrative findings related to abuse or neglect. By signing the form, applicants authorize the Illinois Department of Public Health and other relevant agencies to conduct background checks. This process ensures that all necessary information is collected to assess the applicant's suitability for employment in health care roles. The form also emphasizes the importance of providing accurate information, as any discrepancies could impact the application outcome. Once completed, the form must be mailed to the Illinois Department of Public Health, which will then initiate further steps, including fingerprinting, to finalize the waiver application.
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STATE OF ILLINOIS
Illinois Department of Public Health
HEALTH CARE WORKER WAIVER APPLICATION
Illinois Department of Public Health
Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761
Phone
All information requested on this application must be provided before you will be considered for a waiver. Type or print clearly in ink.
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Today’s Date |
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Name |
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(First, Full Middle and Last) |
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Address |
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(Street, Apartment #, P. O. Box) |
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(City, State, ZIP Code) |
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Maiden Name (or other name(s) used)
Telephone |
Social Security Number (required) |
I hereby authorize the Illinois Department of Public Health, the Department’s designee that trains or tests health care workers, a staffing agency, or the health care employer to request a
I understand that the information requested below regarding sex, race, height, eye color, and date of birth is for the sole purpose of identification, the gathering of the above mentioned information and the processing of this waiver application. This information will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.
Male
Female Race |
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Height |
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Eye Color |
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Date of Birth |
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AChinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander B Black or African American (Not Hispanic or Latino)
H Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) I American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states
of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition. U Of undetermined race or of untold mixture
W Caucasian (not Hispanic or Latino)
Work History – If you have previously been employed, you must provide an entire work history or attach a complete resume. Start with your current employer. Attach addition pages if necessary.
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Separation Date |
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Employer’s Address, City, State, ZIP Code |
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Employer |
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Date Started |
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Employer’s Address, City, State, ZIP Code |
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Other states where you have lived or worked |
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If the use of alcohol or other drugs was involved in the offense, were you ordered to participate in a rehabilitation program as part of the
judgment? |
Yes |
No |
If yes, you must provide proof of successful completion of the rehabilitation program. |
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Were you required to pay a fine in connection to a disqualifying offense? |
Yes |
No |
If yes, you must provide |
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proof of having paid all fines unless you are on a payment schedule. If on a payment schedule, you must provide proof that you are
If you were released on probation (or mandatory supervised release) or parole, you must provide proof of having successfully completed it.
Have you been certified as a nurse aide/assistant in another state? |
Yes |
No |
If yes, you must attach a copy of |
your certification or verification information (such as your certification number__________________________________).
Name used when certified_____________________________________________. If your current name is different, please attach a copy
of the legal document(s) used to change your name (i.e. marriage certificate, divorce decree, etc.) and a copy of your driver’s license or other picture identification.
Have you ever had an administrative finding of abuse, neglect or theft?
Yes
No
If “yes,” indicate in what state this finding was issued.
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
Yes
No
If “yes,” provide the circumstance surrounding each offense (what happened, how many years have passed since the offense, the individuals involved, your age at the time of the offense, and any other circumstances surrounding the offense) as well as the state in which you were convicted. If you have been convicted in another state, you must provide information concerning those convictions or attach the complete results of a criminal history records check from that state. If you have a federal conviction, you must provide information concerning that conviction or attach the complete results of a criminal history records check from the Federal Bureau of Investigation. If more space is needed, please attach additional pages. Do not include convictions that have been expunged, sealed or were a juvenile adjudication.
A copy of the following items may be submitted with this application but are not required. (This material will not be returned to you)
1.A current or recent employment reference.
2.A character reference.
3.Other evidence demonstrating the ability of the applicant to perform the employment responsibilities competently and evidence that the applicant does not pose as a threat to the health or safety of residents, patients or clients.
I certify that the above is true and correct and give my consent for my name to appear on the Department’s Health Care Worker Registry with the results of my criminal history records check.
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As the parent or guardian of the above named individual, who is younger than the age of 17, I give my consent for this named individual to have a criminal history records check.
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Mail this completed form to Illinois Department of Public Health, Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761. The Department will send you a Livescan Request Form by return mail. You will use the Livescan Request Form to have your fingerprints collected from one of the contracted livescan vendors.
Form Specifications
| Fact Name | Description |
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| Governing Law | The Illinois Waiver form is governed by the Health Care Worker Background Check Act (225 ILCS 46/25). |
| Required Information | Applicants must provide all requested information, including name, address, and Social Security number, to be considered for a waiver. |
| Criminal History Check | By signing the form, applicants authorize a fingerprint-based criminal history records check to assess their suitability for employment. |
| Employment Liability | Health care employers are not liable for failing to hire or retain applicants with certain criminal convictions as outlined in the governing law. |
| Identification Information | Details such as sex, race, height, eye color, and date of birth are collected solely for identification purposes and will not be used for discrimination. |
| Submission Process | Completed forms must be mailed to the Illinois Department of Public Health, and applicants will receive a Livescan Request Form for fingerprint collection. |
Illinois Waiver: Usage Guidelines
Filling out the Illinois Waiver form is a straightforward process, but it requires attention to detail. After completing the form, you will need to mail it to the Illinois Department of Public Health. Once they receive your application, they will send you a Livescan Request Form, which you will use to have your fingerprints taken. Follow the steps below to ensure your application is filled out correctly.
- Write today’s date at the top of the form.
- Enter your full name, including first, middle, and last names.
- Provide your complete address, including street, apartment number (if applicable), city, state, and ZIP code.
- If applicable, include your maiden name or any other names you have used.
- Fill in your telephone number.
- Enter your Social Security number, as it is required by law.
- Select your gender by checking either the Male or Female box.
- Specify your race by selecting the appropriate letter from the options provided.
- Fill in your height and eye color.
- Provide your date of birth.
- List your work history, starting with your current employer. Include the dates you started and separated from each job, along with the employer’s address.
- Indicate any other states where you have lived or worked.
- If applicable, answer whether you were ordered to participate in a rehabilitation program for an offense involving alcohol or drugs.
- Answer whether you were required to pay a fine in connection with a disqualifying offense.
- Provide details about any probation or parole you completed.
- If you have been certified as a nurse aide/assistant in another state, indicate yes and attach a copy of your certification.
- Attach legal documents if your current name differs from your certified name.
- Answer questions regarding any administrative findings of abuse, neglect, or theft.
- Indicate whether you have ever been convicted of a criminal offense other than a minor traffic violation and provide the necessary details if applicable.
- Attach any additional pages if more space is needed for explanations.
- Optionally, include a current employment reference, character reference, or other evidence of your ability to perform employment responsibilities competently.
- Sign and date the form to certify that the information provided is true and correct.
- If you are a parent or guardian signing for someone under 17, provide your signature and date as well.
- Mail the completed form to the address provided at the top of the application.
Your Questions, Answered
What is the Illinois Waiver form?
The Illinois Waiver form is an application that individuals must complete to request a waiver from certain disqualifications related to employment in the health care field. It is managed by the Illinois Department of Public Health and requires detailed personal information, including work history and any criminal background.
Who needs to fill out the Illinois Waiver form?
Anyone seeking employment as a health care worker in Illinois who has a disqualifying background may need to fill out this form. This includes individuals with criminal convictions or those who have had administrative findings of abuse, neglect, or theft.
What information is required on the form?
The form requires personal details such as your name, address, social security number, and date of birth. You must also provide your work history, details of any criminal offenses, and information about any previous certifications as a nurse aide or assistant.
Is my Social Security number mandatory?
Yes, providing your Social Security number is required by law. It is used solely for identification purposes in processing your waiver application.
What happens after I submit the form?
After you submit the completed form, the Illinois Department of Public Health will review your application. They will then send you a Livescan Request Form by return mail, which you will use to have your fingerprints collected.
Can I submit additional documents with my application?
Yes, you may submit additional documents such as employment references, character references, or any evidence demonstrating your ability to perform the job responsibilities competently. However, these documents are not required and will not be returned to you.
What if I have a criminal conviction?
If you have a criminal conviction, you must provide details about the offense, including what happened, how many years have passed, and your age at the time. If the conviction occurred in another state, you will need to provide that information or attach a criminal history records check from that state.
How does the waiver process work for minors?
If the applicant is under 17 years old, a parent or guardian must sign the form to give consent for a criminal history records check. This ensures that the necessary background checks are conducted for younger individuals.
What if I have previously been certified in another state?
If you have been certified as a nurse aide or assistant in another state, you should attach a copy of your certification or verification information to your application. This helps in evaluating your eligibility for the waiver.
Where do I send the completed Illinois Waiver form?
You should mail the completed form to the Illinois Department of Public Health at the address provided: Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761.
Common mistakes
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Neglecting to Provide All Required Information: It is crucial to fill out every section of the waiver form. Omitting any requested information can lead to delays or even denial of your application. Always double-check that you have included your name, address, Social Security number, and other required details.
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Using Incomplete or Illegible Information: The form must be completed clearly, either by typing or using ink. If the information is hard to read or incomplete, it may cause confusion and result in processing issues.
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Failing to Attach Necessary Documentation: If you have a criminal record, rehabilitation proof, or prior certifications, ensure you attach all relevant documents. Missing these can hinder the evaluation of your application.
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Ignoring Name Changes: If your current name differs from the one on your previous certifications or legal documents, you must provide proof of the name change. This can include marriage certificates or divorce decrees. Failing to do so may lead to complications.
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Overlooking Signature Requirements: Remember to sign and date the application. An unsigned form is not valid and will not be processed. Both the applicant and, if applicable, the parent or guardian must provide their signatures.
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Not Following Submission Instructions: Ensure you mail the completed form to the correct address. Sending it to the wrong location can result in significant delays. Always verify the mailing address before sending your application.
Documents used along the form
The Illinois Waiver form is an important document for health care workers seeking to obtain a waiver regarding their criminal background checks. In conjunction with this form, several other documents may be necessary to ensure a complete application. Below is a list of commonly used forms and documents that accompany the Illinois Waiver form.
- Livescan Request Form: This form is sent by the Illinois Department of Public Health after the waiver application is submitted. It is used to collect fingerprints through authorized vendors for a criminal background check.
- Employment History Form: This document outlines the applicant's work history. It includes details about previous employers, dates of employment, and addresses, which are essential for the background check process.
- Character Reference Letter: A letter from a professional or personal contact attesting to the applicant's character and suitability for employment in the health care field. This can help strengthen the application.
- Proof of Rehabilitation: If applicable, documentation showing successful completion of any required rehabilitation programs following a disqualifying offense. This proof is vital for demonstrating the applicant's commitment to change.
- Certification Verification: If the applicant has been certified as a nurse aide or assistant in another state, they must provide a copy of that certification or verification details. This confirms their qualifications and experience in the health care sector.
Completing the Illinois Waiver form and gathering the necessary accompanying documents is crucial for a smooth application process. Each document plays a significant role in assessing the applicant's qualifications and background, ensuring that they are suitable for employment in the health care field.
Similar forms
The Illinois Waiver form shares similarities with several other documents that also involve consent and disclosure for background checks or employment verification. Below are four such documents:
- Employment Application: Like the Illinois Waiver form, an employment application requires personal information, including social security numbers and work history. Both documents aim to assess an individual's suitability for a position, often including consent for background checks.
- Background Check Authorization Form: This document explicitly grants permission for employers to conduct a background check. Similar to the Illinois Waiver form, it often requests personal identification details and outlines the information that may be disclosed.
- Release of Information Form: This form allows third parties to access an individual's personal records, such as criminal history or employment verification. Both the release form and the Illinois Waiver require informed consent and detail what information can be shared.
- Health Care Worker Registry Application: This application is specifically for health care workers and includes similar requirements for personal information and background checks. Like the Illinois Waiver, it aims to ensure that applicants meet the necessary standards for employment in health care settings.
Dos and Don'ts
When filling out the Illinois Waiver form, it is crucial to follow certain guidelines to ensure your application is processed smoothly. Here are five essential dos and don’ts to keep in mind:
- Do provide all required information. Ensure that every section of the form is filled out completely, including your name, address, and Social Security number.
- Do print clearly. Whether you are typing or writing in ink, clarity is vital. This helps prevent any misunderstandings or misinterpretations of your information.
- Do attach necessary documents. If you have had prior employment or certifications, include copies of relevant documents as specified in the form.
- Don't omit any criminal history. Be honest about any past convictions or offenses. Failure to disclose this information can lead to delays or denial of your application.
- Don't forget to sign and date the form. An unsigned application will not be processed, so double-check that you have provided your signature where required.
Following these guidelines can significantly enhance your chances of a successful application. Pay attention to detail, and take your time to ensure everything is accurate and complete.
Misconceptions
Misunderstandings surrounding the Illinois Waiver form can lead to confusion for applicants. Here are ten common misconceptions clarified:
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Providing personal information is optional.
Many believe that they can skip sections of the form. In reality, all requested information must be provided for the application to be considered.
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The waiver guarantees employment.
Some applicants think that submitting the waiver ensures they will be hired. However, the waiver only assesses eligibility and does not guarantee job placement.
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Only criminal convictions matter.
Applicants often assume that only convictions are relevant. The form also considers administrative findings of abuse, neglect, or theft, which can affect eligibility.
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Social Security numbers are not required.
There is a misconception that providing a Social Security number is optional. In fact, it is legally required for processing the waiver application.
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All offenses can be expunged.
Some individuals believe that any criminal offense can be erased from their record. However, certain offenses cannot be expunged, and these will still be considered in the application process.
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Proof of rehabilitation is not necessary.
Applicants may think that if they completed a rehabilitation program, they do not need to provide proof. In reality, documentation of successful completion is required if rehabilitation was part of their judgment.
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Submitting additional documents is discouraged.
Some believe that sending extra documentation will complicate their application. However, providing references or evidence of competency can strengthen their case.
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The waiver process is quick and straightforward.
There is a common belief that the waiver application will be processed rapidly. In truth, the timeline can vary significantly based on individual circumstances and the completeness of the application.
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Once submitted, the application cannot be updated.
Many applicants think they cannot make changes after submission. However, they can provide additional information or corrections if necessary.
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Health care employers are liable for hiring decisions.
Some individuals assume that employers are liable for hiring applicants with certain convictions. The waiver states that employers are not held liable for these decisions, provided they follow the guidelines.
Key takeaways
Filling out the Illinois Waiver form is an important step for health care workers seeking a waiver from disqualifying offenses. Here are key takeaways to keep in mind:
- Complete Information Required: Ensure all requested information is filled out accurately. Incomplete applications will not be considered.
- Authorization for Background Check: You must authorize the Illinois Department of Public Health to conduct a fingerprint-based criminal history check.
- Social Security Number: Providing your Social Security number is mandatory as per legal requirements.
- Work History: A complete work history is necessary. Include all previous employers and their addresses.
- Proof of Rehabilitation: If applicable, attach proof of successful completion of any rehabilitation program related to disqualifying offenses.
- Documentation for Name Changes: If your name has changed, include legal documents such as marriage certificates or divorce decrees.
- Criminal Offenses Disclosure: Disclose any criminal offenses, providing details about each situation. Do not include expunged or sealed convictions.
- Submission of Additional References: While not required, submitting references can strengthen your application.
- Mailing Instructions: After completing the form, mail it to the specified address to initiate the waiver process.
Taking these steps seriously can expedite your application and improve your chances of receiving a waiver. Ensure you double-check all information before submission to avoid delays.