I hereby authorize the Warroad Care Center dba Warroad Senior Living Center to contact schools, former places of employment, credit organizations, law enforcement agencies and/or persons who may assist in determining my suitability for employment. Additionally, I release those individuals and/or organizations contacted from all liability, whatsoever, for issuing the requested information.

I hereby authorize investigation of all statements contained in this application and understand that any misrepresentation may be cause for rejection of this application or dismissal after employment. Additionally, I understand that nothing in this application form, or any other WCC policy/procedure/handbook shall constitute any type of employment contract. If employment occurs, I understand that I have the right to terminate for any reason or no reason and acknowledge that WCC retains the same right. If a conditional offer of employment is made, employment is contingent upon satisfactory completion of all pre-employment procedures including reference checks and physical examination.

Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following: 1. Purpose and intended use of the information: Minnesota Statutes, section 144.057, requires the Minnesota Department of Human Services (OHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. OHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by OHS, the corrections system will report new criminal convictions for disqualifying crimes to OHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS. 2. Whether you may refuse or are legally required to provide the Information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study. 3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified. 4. Known consequences that will arise from refusing to supply the requested information: Only items identified as "optional" may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services. 5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. Theinformation about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent. 6a. If CURRENT background study results in a disqualification that is set aside upon reconsideration: If you are disqualified as a result your background study, and you request reconsideration and your disqualification is set aside for the program/agency that initiated the current background study, subsequent background studies initiated by other programs/agencies may result in the disqualification being set aside for other programs/agencies when the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C. 15, subdivision 1 or 2; 2. the program that initiates the subsequent background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside; 3. the commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. the previous set aside was not limited to a specific person(s) receiving services.If the above criteria are met, the notice of disqualification sent to the program/agency that initiates the subsequent background study will state that you are disqualified and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. (§245C.22, subd. 5) 6b. If a PREVIOUS background study resulted in disqualification that was set aside: If you were the subject of a previous background study which resulted in your disqualification, and your disqualification was set aside upon reconsideration, DHS will review the information in your record in connection with your current background study and determine whether the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C.15, subdivision 1 or 2; 2. the program that initiated the current background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside; 3. the commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. the previous set aside was not limited to a specific person(s) receiving services. If the above criteria are met, the notice of disqualification sent to the program/agency that initiated the current background study will state that you are disqualified and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. (§245C.22, subd. 5)

I have received the BACKGROUND STUDY PRACTICE NOTICE and authorize the Minnesota Department of Human Services to disclose all history records information to Warroad Senior Living Center for the purpose of employment with this agency.