Customer Service Project Managers
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Office of Safety & Security
Criminal Background Check Consent Form
(Updated, As of 3/1/2019)
Instructions: To enhance safety and security of APS students and staff, hiring managers, school administrators, program/project managers, and volunteer coordinators, etc. should complete this consent form granting APS permission to perform fingerprinting and criminal background check services. Fingerprinting and criminal background checks are required to authorize: (1) issuance of an APS identification (ID) badge, and/or (2) controlled access to APS facilities for all APS employees, contractors, volunteers, and district partners. All fields on the consent form below must be completed, reviewed, and signed by current and prospective applicants to ensure accurate and timely processing of requested services. To avoid safety risks, fingerprinting and background check, ID badging, and access control services will not be completed without proper, advanced approval of a completed request form. All completed, approved request forms should be submitted at the time of service to maximize the customer service experience for every prospective APS employee, contractor, volunteer, and/or district partner. Applicant Name:
Current Address:
City: State: Zip Code:
Date of Birth: Country of Birth: State of Birth:
Social Security Number: - - Race/Ethnicity: Gender: Female Male Eye Color: Natural Hair Color: Height: Weight:
Phone Number: - Email Address:
Type of Fingerprinting & Background Check Request: (Select one.)
Contractor District Partner New Hire/Prospective APS Employee Re-Certification/Renewal Volunteer
Other, please specify:
Applicant Status:
• “Current APS Staff” complete the following fields: o Current APS Title: Employee ID/Lawson Number:
• “Prospective APS Staff” complete the following fields: o Prospective APS Title: Hire/Start Date:
• If “Current Contractor/Volunteer/District Partner Staff” complete the following fields: o Current Title: Company/School Name:
• If “Prospective Contractor/Volunteer/District Partner Staff” complete the following fields: o Prospective Title: Company/School Name: _
Requested Services & Pricing: (Select all services that apply.)
Fingerprinting & Background Check + APS Identification (ID) Badge – No Access Required ($45)
Fingerprinting & Background Check + APS Identification (ID) Badge – Access Required ($45)
APS Identification (ID) Badge Only – Initial/First-time Badge – No Access Required ($5)
APS Identification (ID) Badge Only – Replacement Badge – Access Badge ($15)
APS Identification (ID) Badge Only – Replacement Badge– No Access Badge ($5) Important Notes: The applicant must bring the following items to complete requested services:
• An unexpired form of photo identification. (e.g., acceptable forms of ID include: Driver’s License; State-Issued Identification Card; Permanent Resident Card, or U.S. Passport.)
• All payments must be in the form of a credit card, money order, or a cashier’s check made payable to: Atlanta Public Schools. o Fingerprinting & Background Check and Identification (ID) Badge fees are the responsibility of the individual not APS. o No cash or personal check payments can be accepted; no exceptions. INTERNAL OFFICE USE ONLY
Payment Received: Yes No Initials:
Background Request Confirmed: Yes No
Copy of Photo ID Attached: Yes No
Performed Fingerprint Scan: Salaam Morgan Other: Name of Company: _
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Office of Safety & Security
Criminal Background Check Consent Form
(Updated, As of 3/1/2019)
Instructions: To enhance safety and security of APS students and staff, hiring managers, school administrators, program/project managers, and volunteer coordinators, etc. should complete this consent form granting APS permission to perform fingerprinting and criminal background check services. Fingerprinting and criminal background checks are required to authorize: (1) issuance of an APS identification (ID) badge, and/or (2) controlled access to APS facilities for all APS employees, contractors, volunteers, and district partners. All fields on the consent form below must be completed, reviewed, and signed by current and prospective applicants to ensure accurate and timely processing of requested services. To avoid safety risks, fingerprinting and background check, ID badging, and access control services will not be completed without proper, advanced approval of a completed request form. All completed, approved request forms should be submitted at the time of service to maximize the customer service experience for every prospective APS employee, contractor, volunteer, and/or district partner. Statement of Consent:
This section is to be completed by the Applicant. Please print all information. I,
LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME (if applicable) have applied for a position within Atlanta Public Schools (APS). This form provides consent to conduct fingerprinting and a criminal background records check by the Atlanta Public Schools – Office of Safety & Security. I also authorize the release of such information to the Atlanta Public Schools now and at any time during my employment, and release, discharge, and waive any and all claims, which may arise against me for the release of accurate information.
I authorize APS to receive any criminal or driver’s history records information pertaining to me, which may be on file in any state or local criminal justice agency. I further give consent to APS to have my fingerprints taken as part of the employment process and perform periodic criminal history background checks for the duration of my employment or affiliation with the Atlanta Public Schools. Fingerprinting for employment as required by O.C.G.A. § 20-2-211.1 is a requirement and will be administered by the Atlanta Public Schools – Office of Safety and Security.
I understand that the Georgia Criminal Information Center (GCIC), APS employees, nor any other agency or employees of the State of Georgia shall be responsible for the accuracy of information nor have any liability for defamation, invasion of privacy, negligence or any other claim in connection with any dissemination of information pursuant to this fingerprinting and criminal background record check and shall be immune from suit based upon any such claims.
Applicant’s Signature: Date:
Page 2 of 7
Prospective APS Staff/Stakeholders Page 2 of 5
Office of Safety & Security
Criminal Background Check Personal Affirmation
(Updated, As of 3/1/2019)
Statement of Personal Affirmation:
Check the appropriate box for each question. Include only events after the age of 16 years old. If you answer “YES” to any question, an explanation and supporting documentation – including any final court disposition documents – may be requested. Documents MUST be submitted within five (5) business days of the request. All responses must be completely truthful. APS Staff completing re-certification and/or renewals must verify accuracy of each question and make any necessary updates to initial/prior records on file. Falsification of this document may result in termination of your employment.
1. Have you resigned or been discharged from any position, including the armed forces, while under suspicion of having engaged in criminal, immoral, or unprofessional conduct, or are you now under investigation for any such charge?
Yes No
2. Have you been convicted of a felony or misdemeanor, or pled nolo contendere or first offender, or are you now under investigation for any offense, other than a minor traffic offense?
Yes No
3. For the purpose of this form “Driving Under the Influence” (DUI) [of alcohol or other drugs] and “Driving While Impaired” (DWI) offenses must be reported. Please respond accurately even if you have been advised that there will be no charge on your record. Have you ever been charged with a DWI/DUI?
Yes No
4. Have you ever surrendered a license/permit; or had one denied, revoked, or suspended; or is any investigation or adverse action now pending against you?
Yes No
Knowing that false statements made on this form may constitute grounds for disciplinary action, and may constitute grounds for legal action, I affirm that, to the best of my knowledge, all information is true and correct. I hereby give permission to Atlanta Public Schools to obtain copies of any criminal and personnel records relating to me, including records, which may have been sealed or expunged, which are held by any local, state, or federal government agency or private entity, and authorize any such agency or entity to release those records to the Atlanta Public Schools. PRINT NAME:
LAST NAME FIRST NAME MIDDLE INITIAL
SIGNATURE:
DATE
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Office of Safety & Security
Non-Criminal Justice Applicant’s Privacy Rights
(Updated, As of 2/4/2021)
Criminal Background Check Consent Form – Attachment A: APS Copy As an applicant who is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/ biometric-based criminal history check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulation (CFR), 50.12, among other authorities. You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized. You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared or explained. You must be advised in writing of the procedures for obtaining a change, correction, or update of your criminal history record as set forth at 28 CFR 16.34.
You must be provided the opportunity to complete or challenge the accuracy of the information in your criminal history record (if you have such a record).
If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on the information in the criminal history record.
If agency policy permits, the officials may provide you with a copy of your criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may find information regarding how to obtain a copy of your Georgia criminal history record at the GBI website: https://gbi.georgia.gov/services/obtaining-criminal- history-record-information-frequently-asked-questions Information regarding how to obtain a copy of your FBI criminal history record is located at the FBI website: https://www.edo.cjis.gov If you decide to challenge the accuracy or completeness of your criminal history record, you should contact and send your challenge to the agency that contributed the questioned information. If the disputed arrest occurred in the State of Georgia, you may send your challenge directly to the GCIC. Contact information for the GCIC can be found at https://gbi.georgia.gov/services/ obtaining-criminal-history-record-information-frequently-asked-questions Alternatively, you may send your challenge directly to the FBI by submitting a request via https://www.edo.cjis.gov. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenge entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) You have the right to expect that officials receiving the results of the criminal history record check will use it only for the authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. For more information, contact:
Address:
Phone Number:
Email Address:
130 Trinity Avenue SW, Atlanta, GA 30303
**************@********************.**
PRINT NAME:
LAST NAME FIRST NAME MIDDLE INITIAL
SIGNATURE:
DATE
Page 4 of 7
Office of Safety & Security
Privacy Act Statement
(Updated, As of 2/4/2021)
Criminal Background Check Consent Form – Attachment B: APS Copy Authority:
The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose:
Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of Routine Uses:
Atlanta Public Schools – Office of Safety & Security Address: 130 Trinity Avenue SW, Atlanta, GA 30303
Phone Number: 404-***-****
Email Address: **************@********************.** PRINT NAME:
LAST NAME FIRST NAME MIDDLE INITIAL
SIGNATURE:
DATE
Page 5 of 7
Office of Safety & Security
Non-Criminal Justice Applicant’s Privacy Rights
(Updated, As of 2/4/2021)
Criminal Background Check Consent Form – Attachment A: Applicant’s Personal Copy As an applicant who is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/ biometric-based criminal history check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code
(U.S.C.) Section 552a, and Title 28 Code of Federal Regulation (CFR), 50.12, among other authorities. You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized. You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared or explained. You must be advised in writing of the procedures for obtaining a change, correction, or update of your criminal history record as set forth at 28 CFR 16.34.
You must be provided the opportunity to complete or challenge the accuracy of the information in your criminal history record (if you have such a record).
If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on the information in the criminal history record. If agency policy permits, the officials may provide you with a copy of your criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may find information regarding how to obtain a copy of your Georgia criminal history record at the GBI website: https://gbi.georgia.gov/services/obtaining-criminal-history-record-information- frequently-asked-questions Information regarding how to obtain a copy of your FBI criminal history record is located at the FBI website: https://www.edo.cjis.gov
https://www.edo.cjis.gov. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenge entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency.
(See 28 CFR 16.30 through 16.34.)
You have the right to expect that officials receiving the results of the criminal history record check will use it only for the authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. For more information, contact:
Atlanta Public Schools – Office of Safety & Security Address:
Phone Number:
Email Address: **************@********************.** PRINT NAME:
LAST NAME FIRST NAME DATE
SIGNATURE:
DATE
Page 6 of 7
Prospective APS Staff/Stakeholders Page 5 of 5
For more information, contact:
Office of Safety & Security
Privacy Act Statement
(Updated, As of 2/4/2021)
Criminal Background Check Consent Form – Attachment B: Applicant’s Personal Copy Authority:
The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose:
Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/ biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket.
Routine Uses:
Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non- governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. Atlanta Public Schools – Office of Safety & Security Phone Number:
Email Address:
130 Trinity Avenue SW, Atlanta, GA 30303
**************@********************.**
PRINT NAME:
LAST NAME FIRST NAME MIDDLE INITIAL
SIGNATURE:
DATE
Page 7 of 7
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