Dear Prospective Phlebotomy Student: Thank you for your ...€¦ · Dear Prospective Phlebotomy...
Transcript of Dear Prospective Phlebotomy Student: Thank you for your ...€¦ · Dear Prospective Phlebotomy...
Dear Prospective Phlebotomy Student:
Thank you for your interest in the Phlebotomy Certification course at MACC located in Mexico,
Missouri. Enclosed you will find an application packet for the fall/spring Phlebotomy
Certification course. Please review all documents carefully. The deadline for returning all
documents for the spring semester course is the first Friday in January. The deadline for
returning all documents for the fall semester course is the first Friday in August. All completed
application forms, immunization records, background checks and drug screen results are
all required in our office before enrollment in the class is allowed.
Please use the following checklist as a guide to help you through the application process:
Completed Form/Document
MACC Application Online at https://www.macc.edu/admissions/steps-to-admissions
Phlebotomy Program Application
Record Review Permission Form
Release of Information Form
Fingerstick Release Form
Instructor Reference Form
Employer Reference Form
Other Reference Form
Essential Qualifications Form NOTARIZED
Immunization Records Form
Missouri State Highway Patrol Background Check ($14.00 Name Search) Form or
Hard Copy Results
Background Check Advantage Request Form ($2.50 check or money order made
payable to MACC for this background check)
Caregiver Background Screening Form
Directions to Mid-Mo Drug Testing Collection Site
Immunizations
Proof of the following immunizations are required before enrolling into the Phlebotomy
Certification course:
Hepatitis B vaccine: There are three inoculations. Students must have at least begun the
series;
Two MMR immunizations or positive titer;
Positive immune varicella titer or an immunization;
DPT inoculation series;
A 2-step TB test or documentation of having had two TB tests in two years or chest x-ray
if a positive reaction has been documented;
Some sites may require an influenza vaccine; please be advised this might be necessary
too, once your clinical site has been decided
Drug Screen
Proof of a negative 11 panel drug screen must be received before enrollment in the phlebotomy
class is allowed. A map to the collection site is included in this packet.
MSHP Criminal Background Check
Send the completed Missouri State Highway Patrol Criminal Background Check, with $14.00
payment, directly to the Missouri State Highway Patrol (see address on the form). Send for the
background check early because it may take up to six weeks to be completed and arrive in our
office. For a small additional processing fee, a faster service option is available. The Missouri
Automated Criminal History Site (MACHS) may be accessed at www.machs.mshp.dps.mo.gov.
If you select the online option, you will need to print and include the results with your
application packet.
Caregivers Background Check
Fax or mail the Caregivers Background Screening to the fax number or address on the back of
the form. Use “Option 4” in the bottom right hand corner as the correct fax number or mailing
address. We can fax this form for you if you do not have access to a fax machine.
Office of Inspector General Background Check
Complete the MHA “Background Check Advantage” OIG form and send it to our office with
cash, check or money order in the exact amount for $2.50. Make checks payable to MACC.
We will process this background check ourselves.
Reference Forms
In addition, please be advised that all reference forms must be returned to our office in a sealed
envelope from the persons of your choosing. References should be from teachers, ministers or
supervisors. No friends or relatives please.
Course Enrollment Form
Once you have submitted your completed application packet, please contact the MLT Program
Coordinator or the Nursing Administration office to obtain your enrollment form for the course.
You may not enroll for this course without this enrollment form. The enrollment form must be
signed by MLT Program Coordinator before you can enroll.
I look forward to working with you and the rest of your class. If you have further questions, do
not hesitate to contact me via email or phone at the number listed below.
Sincerely,
Alese M. Thompson MS, MLS (ASCP)CM
Executive Director of MHPC Medical Laboratory Technician Program
(573) 582-0817 ext. 13624
MACC
PHLEBOTOMY CERTIFICATION COURSE
APPLICATION
The deadline for returning all documents for the spring semester course is the first
Friday in January. The deadline for returning all documents for the fall semester
course is the first Friday in August.
Legal
Name_____________________________________________________________________
Last First Middle
Previous Names: _______________________________________________________________
Address_______________________________________________________________________
Street City State Zip
Phone Number (_____) _______________Email Address: ______________________________
Emergency Contact: ________________________________________ (_____) _____________
Last First Phone Number
PREVIOUS EDUCATION
Schools
Attended Name and Location Dates
Certificate, Diploma, or
Degree Awarded Year
High School
College or
Universities
MLT Schools
Other
MACC does not discriminate on the basis of race, color, national origin, sex, disability, age, and marital or parental
status in admissions, programs and activities, and employment.
Inquiries concerning Section 504 of the Rehabilitation Act of 1973, which guarantees access to education regardless
of disability, should be directed to: Angela Duvall, Office of Student Services, 101 College Avenue, Moberly, MO
65270, 660-263-4110 ext. 278. All other inquiries concerning nondiscrimination, including equal opportunity and
Title IX, should be directed to one of the following people: Dr. Jeff Lashley, Office of Academic Affairs, 101
College Avenue, Moberly, MO 65270, 660-263-4110 ext. 216 or Sonda Stuart, Career and Placement Services, 101
College Avenue, Moberly, MO 65270, 660-263-4110 ext. 232. Students with documentable disabilities as addressed
by the Americans with Disabilities Act may register proper documentation with the Office of Student Services. The
Student Services Office will then notify appropriate instructors of suggested official accommodations. Students may
also wish to personally inform their instructors of their particular disabilities.
MACC
PHLEBOTOMY CERTIFICATION COURSE
RECORD REVIEW PERMISSION FORM
Have the following documents sent to the address listed below:
Moberly Area Community College
Attn: Alese Thompson
Medical Laboratory Technician Program
2900 Doreli Lane, Mexico, MO 65265
The deadline for returning all documents for the spring semester course is the first
Friday in January. The deadline for returning all documents for the fall semester
course is the first Friday in August.
1. A completed, acceptable Criminal Background check (Complete the form, enclose a $14.00
check or money order made out to the “State of Missouri, Criminal Record System”, and
send to the address on the form. The State Police will send the background check to the
Program Coordinator).
2. Three letters of reference on the designated forms.
3. Submit to a drug screen through Mid-Mo Drug Testing (Once completed, the drug testing
facility will send the results to the Program Coordinator).
4. Submit inoculation records for the following to the Program Coordinator:
a. All 3 doses of Hepatitis B vaccine or documentation of having begun the series;
b. MMR vaccine series;
c. Positive immune varicella titer or an immunization;
d. DPT inoculation series within 10 years;
e. 2-step TB test or 2 TB tests within 2 years or chest x-ray if a positive reaction has
been documented.
f. Influenza vaccine
5. A completed Caregiver Registry background check (to include the Employee
Disqualification List background check) form sent to the Program Coordinator.
6. A completed, acceptable Background Check Advantage form that includes OIG
Medicare/Medicaid Fraud and Abuse background check (Complete the form, attach a check
or money order for $2.50 and send to the Program Coordinator for faxing).
7. Complete form to allow release of background information.
8. Signed and notarized Essential Qualifications form.
I understand that all information received from references as well as shot records and
background check, will be reviewed by the Program Coordinator or by an admissions
committee, and I hereby grant permission to have my records reviewed.
___________________________________________________ _________________
Signature Date
MACC
PHLEBOTOMY CERTIFICATION COURSE
RELEASE OF INFORMATION FORM
Full Name:____________________________________________________________________
Maiden/Alias Name(s):__________________________________________________________
Address:______________________________________________________________________
City:________________________________ State:____________________ Zip:___________
Social Security Number:_________________________________________________________
Date of Birth:__________________________________________________________________
Place of Birth:__________________________________________________________________
I authorize Moberly Area Community College to request and obtain a copy of my criminal
background as provided in Section RSMo. 610.120 and make an inquiry to the Department of
Social Services regarding the “Employee Disqualification List” as provided in Section RSMo.
660.315. I also authorize Moberly Area Community College to request and obtain a copy of my
drug screen results, immunization records, a Division of Family Services background check
regarding child abuse or neglect, and a background check with the Office of Inspector General. I
also realize I must provide a criminal background check for each state in which I have lived
within the past ten (10) years.
I further authorize Moberly Area Community College to provide the necessary documentation of
all the above stated information to individual clinical affiliates, to verify my eligibility to
participate in the clinical experience.
___________________________________________________ _________________
Signature Date
___________________________________________________ _________________
Witness Date
MACC
PHLEBOTOMY CERTIFICATION COURSE
FINGERSTICK RELEASE FORM
I, _______________________________________________release MACC, the Division of
Health Sciences, the instructor, and the student performing the venipuncture and/or fingerstick
blood collection from any responsibility. My signature constitutes that I have been informed of
potential complications and voluntarily agree to participate.
___________________________________________________ _________________
Signature Date
___________________________________________________ _________________
Witness Signature Date
MACC
2900 Doreli Lane
Mexico, MO 65265
Phlebotomy Certification Course
* Instructor REFERENCE
Please return this form to the Executive Director of the MHPC Medical Laboratory Technician Program, at
the MACC, Mexico by the first Friday in January if you are applying for the spring semester and by the first
Friday in August if you are applying for the fall semester. Thank you for your assistance.
__________________________is a candidate for admission into the Phlebotomy course at Mexico, Missouri.
Please note: I hereby authorize parties who receive requests to give full and complete information as may be
requested by MACC. I further agree that the information will not be disclosed to me and I
thereby waive any right to review this reference form.
___________________________________ ________________________
Student Signature Date
Please Check: APPLICANT'S
CHARACTERISTICS
STRONGLY
AGREE
(1)
AGREE
(2)
DISAGREE
(3)
STRONGLY
DISAGREE
(4)
Reliability/
Accountability
Communication Skills
(Oral and Written)
Good Moral Character
Integrity
Ability to Work
With Others
Ability to Cope With
Stress/Crisis
Initiative
Please indicate whether or not you endorse the applicant:
Endorse with Enthusiasm______ Endorse_______ Do not Endorse_______
Number of courses taken with you_______*
How long have you known applicant?__________ Date:___________________________
Signature___________________________________ Address:________________________
Name:_____________________________________ _______________________________
Position:___________________________________ Telephone: ______________________
*If the potential phlebotomy student does not have a prior instructor to receive an evaluation from, due to an acceptable
reason verified by the Executive Director of the MHPC MLT program, please use this form for an additional reference
from a non-teacher.
MACC
2900 Doreli Lane
Mexico, MO 65265
Phlebotomy Certification Course
EMPLOYER REFERENCE
Please return this form to the Executive Director of the MHPC Medical Laboratory Technician Program, at
the MACC, Mexico by the first Friday in January if you are applying for the spring semester and by the first
Friday in August if you are applying for the fall semester. Thank you for your assistance.
__________________________is a candidate for admission into the Phlebotomy course at Mexico, Missouri.
Please note: I hereby authorize parties who receive requests to give full and complete information as may be
requested by MACC. I further agree that the information will not be disclosed to me and I
thereby waive any right to review this reference form.
___________________________________ ________________________
Student Signature Date
Please Check: APPLICANT'S
CHARACTERISTICS
STRONGLY
AGREE
(1)
AGREE
(2)
DISAGREE
(3)
STRONGLY
DISAGREE
(4) Reliability/
Accountability
Communication Skills
(Oral and Written)
Good Moral Character
Integrity
Ability to Work
With Others
Ability to Cope With
Stress/Crisis
Initiative
Please indicate whether or not you endorse the applicant:
Endorse with enthusiasm______ Endorse_______ Do not endorse_______
Number of years employed with you:___________
How long have you known applicant?__________ Date:___________________________
Signature___________________________________ Address:________________________
Name:_____________________________________ _______________________________
Position:___________________________________ Telephone:______________________
MACC
2900 Doreli Lane
Mexico, MO 65265
Phlebotomy Certification Course
REFERENCE
Please return this form to the Executive Director of the MHPC Medical Laboratory Technician Program, at
the MACC, Mexico by the first Friday in January if you are applying for the spring semester and by the first
Friday in August if you are applying for the fall semester. Thank you for your assistance.
__________________________is a candidate for admission into the Phlebotomy course at Mexico, Missouri.
Please note: I hereby authorize parties who receive requests to give full and complete information as may be
requested by MACC. I further agree that the information will not be disclosed to me and I
thereby waive any right to review this reference form.
___________________________________ ________________________
Student Signature Date
Please Check:
APPLICANT'S
CHARACTERISTICS
STRONGLY
AGREE
(1)
AGREE
(2)
DISAGREE
(3)
STRONGLY
DISAGREE
(4)
Reliability/
Accountability
Communication Skills
(Oral and Written)
Good Moral Character
Integrity
Ability to Work
With Others
Ability to Cope With
Stress/Crisis
Initiative
Please indicate whether or not you endorse the applicant:
Endorse with enthusiasm______ Endorse_______ Do not endorse_______
How do you know the applicant? _____________
How long have you known applicant?__________ Date:___________________________
Signature___________________________________ Address:________________________
Name:_____________________________________ _______________________________
Position:___________________________________
Telephone:______________________
6/17/2019
MACC MISSOURI HEALTH PROFESSIONS CONSORTIUM
MEDICAL LABORATORY TECHNICIAN PROGRAM
ESSENTIAL REQUIREMENTS
Introduction A graduate with an Associate of Applied Science degree from the MHPC Medical
Laboratory Technician program is educated to enter the practice of laboratory medicine
and qualified to take the accrediting exam from the American Society of Clinical
Pathologists (ASCP). Education in laboratory medicine involves assimilation of
knowledge, acquisition of skills, and development of judgment through handling patient
specimens, manipulation of instrumentation, and working with patients, doctors, nurses,
and other health care professionals. Medical laboratory technicians must be able to work
independently and as a part of a team. They must be able to make appropriate decisions
regarding patient results.
The Medical Laboratory Technician program’s curriculum requires students to engage in
diverse complex and specific experiences primarily in the laboratory but also with
patients. Unique combinations of cognitive, affective, psychomotor, physical, and social
abilities are required to perform these functions successfully. These abilities are
necessary to ensure the health and safety of patients, fellow students, laboratory
personnel, faculty, and other healthcare providers.
Policy MACC has a vested interest in the welfare of patients served by graduates of the Medical
Laboratory Technician program. The College also has a responsibility to its clinical
affiliates, future employers, program instructors, and students enrolled in the program.
Therefore, not only have academic standards been established but also non-academic
essential requirements. These requirements, as distinguished from academic standards,
refer to cognitive, physical, and behavioral abilities that students must have to acquire the
knowledge and skills of the curriculum successfully. The standards must be met, with or
without reasonable accommodation, in order for students to participate in the program.
Discrimination is prohibited based on race, color, sex, national origin, age, disability,
marital status, religion, or veteran status in compliance with the Americans With
Disabilities Act (PL 101-336).
The essential abilities necessary to acquire or demonstrate competence in laboratory
medicine and necessary for successful admission and continuance in the Medical
Laboratory Technician Program include but are not limited to the following:
Motor Skills and Mobility Dexterity and fine motor skills to perform laboratory testing and specimen
manipulation
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Physical ability to maneuver within the laboratory area to perform testing and the
patient treatment area to collect specimens
Sufficient touch discrimination to distinguish veins when performing
venipunctures
Candidates should have sufficient motor function to move about the laboratory and the
dexterity to manipulate equipment, laboratory supplies, biohazards, chemical hazards,
and patient specimens. They must have the ability to operate instrumentation safely to
avoid harm to self or others. Laboratory workers interpret data from computer screens
and perform data input. The candidate must be able to perform phlebotomy; that is,
moving from room to room or patient to patient, stooping or bending, to draw blood
safely. The candidate must be able to lift, carry, push, and pull. The candidate must be
able to move quickly and/or continuously as well as tolerate long periods of standing or
sitting (laboratory workers spend approximately 75% of each day standing or walking).
The candidate must be able to travel to clinical laboratory sites for practical experience.
Candidates must be willing to work with blood, infectious organisms, and chemical
reagents.
Sensory/Observation Visual ability to perform and interpret test results, and to read charts, graphs,
instrument displays, and the printed word on paper or a computer monitor
Visual ability to distinguish gradients of colors Note: Color blindness does not
necessarily preclude admission to the program
Tactile ability to perform laboratory tests using assorted devices
A candidate must be able to acquire the information presented in demonstrations and
experiences in basic laboratory science. He or she must be able to discriminate subtle
structure and consistency differences in specimens and cultures both macroscopically and
microscopically. Additionally, he or she must be able to evaluate patient/client responses
correctly; accurately read results or measurements on patient-related equipment; and hear
monitor alarms, emergency signals, telephone interactions, and cries for help. The
candidate must be able to tolerate odors and work in close and crowded areas.
Communication Effectively communicate in written and verbal form (this includes basic computer
keyboarding)
The candidate must be able to process and communicate effectively in oral and written
forms. The candidate must communicate clearly, effectively, and sensitively with other
students, faculty, staff, patients, and other medical professionals. He or she must be able
to follow oral and written instructions to perform laboratory test procedures correctly.
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Cognitive Ability to master information presented in lectures, written material, and images
Cognitive ability to assess data, make decisions based on data, and provide
complete and accurate results on laboratory testing for quality patient care
The Medical Laboratory Technician program candidate must be able to measure,
mathematically calculate, reason, analyze, integrate, and synthesize information. The
candidate must be able to read and comprehend technical and professional materials. He
or she must be able to evaluate information and engage in critical thinking in the
classroom and clinical setting.
Behavioral/Emotional Emotional stability in potentially stressful circumstances
Behavioral restraint, emotional maturity, and sensitivity to others
The candidate must possess the emotional health required to use his or her intellect in
exercising appropriate judgment and prompt completion of all responsibilities. The
candidate must have the emotional stability to provide professional and technical services
under stressful conditions such as emergency demands and distracting environments.
The candidate must be a team member, honest, compassionate, ethical, responsible, and
able to manage time in order to complete technical procedures within a reasonable time
frame.
Professional Conduct Professionalism and ethical conduct
Candidates must recognize the importance of operating in a moral, ethical way in the
clinical laboratory and the necessity of abiding by high standards of practice. Candidates
must recognize the need for confidentiality.
These standards identify the requirements for admission, retention, and graduation from
the program. It is the responsibility of the student with disabilities to request those
accommodations that he or she feels are reasonable and needed to execute the essential
functions described.
References:
Fritsma, G., Fiorella, B., Murphy, M. (1996). Essential Requirements for Clinical
Laboratory Science.” Clinical Laboratory Science, 9(1), p. 40-43.
American Society of Clinical Laboratory Scientists. (2004). Body of Knowledge,
Clinical Laboratory Scientist. Bethesda, MD: ASCLS.
American Society of Clinical Laboratory Scientists. (2004). Entry Level Curriculum,
Clinical Laboratory Scientist. Bethesda, MD: ASCLS.
6/17/2019
RECEIPT AND ACKNOWLEDGMENT
ESSENTIAL QUALIFICATIONS
The undersigned applicant to the MHPC Medical Laboratory Technician Program hereby
acknowledges receiving, reading, and understanding this essential functions document.
The applicant understands that completion of the MACC Medical Laboratory Technician
program does not mean that the American Society of Clinical Pathologists will issue the
applicant a certificate.
SIGNATURE OF APPLICANT
Date
STATE OF____________________________
COUNTY OF__________________________
On this________________day of ____________________, 20___, before me,
____________________________, Notary Public in and for said state, personally
appeared,_______________________________, known to me to be the person who
executed the within instrument and acknowledged to me that ____________________
executed the same for the purposes therein stated.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal
the day and year last above written.
Notary Public
MACC
PHLEBOTOMY CERTIFICATION COURSE
IMMUNIZATION RECORD FORM
PROOF OF ALL IMMUNIZATIONS MUST BE ATTACHED TO THIS FORM
Please return this form to the Executive Director of the MHPC Medical Laboratory
Technician Program, at the MACC—Mexico by the first Friday in January if you are
applying for the spring semester and by the first Friday in August if you are applying for the
fall semester.
Date(s) Received Immunization Comments
1.
2.
Two MMR immunizations or
positive titer
TDap or DTap
(within last 10 years
1.
2.
2 Step Tuberculin Test
(result must be negative or file needs
chest X ray)
Varicella titer or immunization
1.
2.
3.
Hepatitis B vaccine series
(3 doses or at least begun the series)
Influenza vaccine
REQUEST FOR CRIMINAL RECORD CHECK
PLEASE PRINT OR TYPE.
Telephone (include area code)
SEND REPLY TO (Print or type your mailing label below.)
Missouri State Highway PatrolCriminal Justice Information Services Division
Post Office Box 9500Jefferson City, MO 65102
Please forward the request and fee to:
MISSOURI STATE HIGHWAY PATROL SHP-158S 11/18
fold fold
fold fold
APPLICANT'S LAST NAME FIRST
SEX
MIDDLE JR / SR
MAIDEN / ALIAS LAST NAME FIRST MIDDLE JR / SR
DATE OF BIRTH (MM/DD/YYYY) SOCIAL SECURITY NUMBER RACE
STREET - P.O. BOX CITY STATE ZIP CODE
GENERAL INFORMATION
TYPE OF RECORD CHECK — PROCESSING FEE — METHOD OF PAYMENT
$14.00 NAME SEARCH
Based on NAME, DATE OF BIRTH,AND SOCIAL SECURITY NUMBER.Response will be returned with all openrecords and records of conviction.
$20.00 FINGERPRINT SEARCH
MALE
FEMALE
BLACK
WHITE
INDIAN
ASIAN
OTHER
Fee is payable either by check or money order (NO CASH) to "State of Missouri, Criminal Record System Fund."
Either the Date of Birth OR Social Security Number MUST be provided for processing.
For faster processing criminal record checks are available online at: www.machs.mo.gov
MSHP / CENTRAL REPOSITORY RESPONSE
ADDRESS
(per Sections 43.527 and 43.530, RSMo.)
Open RecordsOpen and Closed Records
$2.00 NOTARY LETTER
Criminal Justice Information Services Division
General Information
The Missouri Criminal Records Repository (MCRR) collects, maintains, and disseminates Criminal History Record
Information (CHRI) as defined by Sections 43.500 and 589.400, RSMo. CHRI is information collected by criminal justice
agencies on individuals and consists of arrests, prosecutions, final dispositions, correctional supervision, and releases.
All felony and serious misdemeanor arrests (referred to as reportable arrests), including offender registration information
as defined under Section 589.400, RSMo, and all alcohol and drug related traffic offenses are reportable to the MCRR.
Criminal background checks may be requested by means of:
1) A Personal Identifier Search (name-based) which searches information based on the name, date of birth, and
social security number of an individual.
2) A Fingerprint Based Search which searches the state’s criminal history files by conducting a fingerprint
comparison of the applicants fingerprints with the criminal (arrest) fingerprints on file with the Central Repository.
Fingerprint images are collected and submitted using the standard federal applicant fingerprint card (FD-258).
The Personal Identifier Search requires a payment of $14.00 per request. The background check results are
considered a “possible match” and will include only open records. Any individual, business, or agency may request
and receive open record information by means of a personal identifier search. Open records include:
§ Records containing convictions, such as plead guilty to, or convicted of.
§ Arrest information that is less than 30 days old from the date of arrest.
§ Charges filed from the prosecutor, awaiting final disposition from the court.
§ Records that contain a suspended imposition of sentence (SIS) during the probation period.
A Fingerprint Based Search requires a payment of $20.00 per request. The results of a fingerprint-based background
check are considered a “positive match” and will provide either open records or closed (complete) records as
requested by the applicant.
An applicant may choose to conduct a fingerprint based criminal record check containing open records thus limiting the
dissemination of criminal history information to only open record information. The Criminal Justice Information Services
(CJIS) Division will release fingerprint-based criminal history information containing only open record information to any
individual, business, or agency when requested by the applicant.
An applicant may choose to conduct a fingerprint-based criminal record check for release of closed records thus
allowing dissemination of all criminal history information on file with the Central Repository. Closed records will only be
released with a record check submitted by means of a fingerprint comparison and will only be released directly to the
applicant or to a qualified entity if authorized in accordance with Section 610.120 and Chapter 43, RSMo. Closed
records include:
§ All criminal history data, including all arrests (filed or not filed charges).
§ Charges that have been nolle prossed, dismissed, or found not guilty in a court of law.
§ Suspended Imposition of Sentence (SIS) after the probation period is complete.
Notary Letters are provided upon request and require an additional $2.00 processing fee, per request. A notary letter
may be requested with either a personal identifier search or a fingerprint search.
PENALTY — A person who knowingly violates any provision of Sections 43.532, 43.540, 610.100, 610.105, 610.106 or
610.120 RSMo is guilty of a class A misdemeanor.
FBI Record Requests
The FBI only has open files meaning that if someone has the authority to receive the records; they receive all that is on
file.
Individuals that need a Federal or Federal Bureau of Investigation (FBI) background check, for personal reasons or for
employment purposes for entities not authorized through Missouri State Statute or the Missouri VECHS program, can
submit fingerprints with an $18.00 fee directly to the FBI. For information on how to obtain a federal background check
directly from the FBI, please refer to information regarding the FBI’s Identity History Summary Check on the FBI’s
website at www.fbi.gov.
Exhibit B
BACKGROUND CHECK ADVANTAGE - Request Form 8/8/2012 Background Check Advantage P.O. Box 6766, Jefferson City, MO 65102 Phone: 573/893-3700 Fax: 573/893-7669
Holly Whitworth
MACC--Mexico Phone: 573-582-0817 ext. 13624
First Name Middle Name Last Name
Alias/Maiden Name Check Alias Name? Will Employee’s Salary Exceed $75,000?
YES - Additional Charges May Apply
NO
Social Security Number Date of Birth Race Gender
- - M F
Mailing Address (NO P.O. Boxes) City State Zip
As part of the student, I consent to the release of my criminal background records and motor vehicle driving records or any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for student. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports. This consent will remain effective until I have affirmatively revoked it.
__________________________________________________ DATE: ______/______/________ Signature of Applicant
BACKGROUND SEARCHES
X OIG (Medicare/Medicaid Fraud & Abuse)
LIST CITY/COUNTY CRIMINAL SEARCHES NEEDED States with county by county access only: CA, MA, WV and WY
County 1:_____________State: _____ County 2:______________State: _____ County 3:_______________State: _____
*Puerto Rico Repository (Felony Only Search & requires Mother’s Maiden Name & Address) ___________________________________ Statewide Criminal—A Statewide/State Repository houses records from all jurisdictions throughout the state.
AL* AK AZ AR* CO CT* DE DC* FL GA* HI ID** IN IA** KS KY LA* ME MD MI MN MS* MT NE NV* NH** NJ NM* NY* NC ND OH OK OR* PA RI* SC SD TN TX UT* VA* VT* WA WI Note: Louisiana, Nevada & Ohio are Felony Only Illinois Healthcare—compliance with IL Healthcare Worker Background Check Act (IL Police Full-State Repository Criminal) MO—includes MO Sex Offender Search at no additional cost (MO State Highway Patrol Full-State Repository Criminal)
* Requested Form(s) & **Requested Special Form(s) must be ATTACHED when ordering or faxed to 573-893-7669
8/8/2012
Mid-Mo Drug Testing Collections: Address: 405 Bernadette Drive, Office D, Columbia, MO 65203
573-234-1872 Cash, Check or Money Order Only
Please send results to:
Alese Thompson MACC--Mexico
2900 Doreli Lane Mexico, MO 65265
or Fax: 573-581-3766