Bring these four items with you to:

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1 U N I V E R S I T Y O F H A W A I I A T M A N O A College of Education Institute for Teacher Education Fingerprinting and Background Check Requirement Students enrolled in the College of Education conduct fieldwork in Hawaii State Department of Education (DOE) classroom settings. In order to work in a classroom with children you must be fingerprinted and clear a DOE background check (DOE OHR & 003 forms attached). Students who plan to work in a field setting for the first time during the fall semester need to complete the fingerprinting requirement June July 21 (and November 8 December 8 for the spring semester). Your timely completion of this requirement within the 30 day time frame specified above will allow sufficient time for processing and not delay your ability to conduct fieldwork and complete course requirements. If you are unable to complete your fingerprinting/background check during the time frame specified above then you should complete it as soon as possible after the appropriate time frame noted above. In order to process your fingerprinting/background check, please prepare the following four items: 1. DOE OHR suitability form (complete sections I, II, III ahead of time) 2. FBI Fingerprint nformation Form Note that on both forms the School/Office (TBD) and Position(s) (UHM IHE College of Education) fields have already been completed. Please do not change these designations. 3. Government issued identification card (e.g., driver s license) 4. Social Security card Bring these four items with you to: If you live anywhere on Oahu or will be moving to Oahu from outside Hawaii, complete your fingerprinting requirement at the following Dole Cannery location, M-F, 8:00a-4:00p. ease ca for an appointment: Hawaii Department of Education Office of Human Resources Employee Background Check Section 650 Iwilei Road, Suite 300 Honolulu, Hawaii (808-3 ) eighbor is and residents If you will be on Oahu during the time frame specified abo e you should complete your fingerprinting at the Dole annery location. f you will be on a neighbor island during the time frame specified abo e you should complete your fingerprinting at one of the following locations. Please contact the appropriate office to make an appointment. If you live in the Kona area, please call the Hawaii District Office in Hilo to see if/when they are scheduling fingerprinting in Kona. Molokai and Lanai students please contact the Maui District Office to make arrangements for fingerprinting on your island. Hawaii District Office Maui District Office Kauai District Office 75 Aupuni Street, Room High Street, 4 th Floor 3060 Eiwa Street Hilo, HI Wailuku, HI Lihue, HI ( ) ( ) ( ) After you complete your fingerprinting the DOE will process the necessary paperwork to determine whether or not you cleared your background check. This process can take anywhere from two days to two months but may take longer in some cases. The DOE will contact the College of Education once you are cleared. Before you are allowed to enter your field placement you must wait until you receive an from the College of Education informing you that your background check has cleared. NOTE: If you are a current employee with the Hawaii State Department of Education (DOE) and have already c eared a DOE background check then no additional action may be required (A+ and after school care providers are not considered DOE employees and need to c ear a DOE background check). The DOE will provide the College of Education with a list of people who are already cleared. Former DOE employees who have been fingerprinted in the past but who have had a break in service need to be fingerprinted again. Fingerprinting/background checks conducted through outside agencies (non Hawaii DOE) are not acceptable. If you have any additional questions about this requirement, please contact: Aaron J. Levine Partnership and Placement Coordinator alevine@hawaii.edu, University Avenue, Everly Hall, Room 223, Honolulu, Hawai i Facsimile: (808) An Equal Opportunity/ Affirmative Action Institution

2 EMPLOYMENT SUITABILITY CHECK FOR DOE EMPLOYEES AND INSTITUTE OF HIGHER EDUCATION TRAINEES I. PERSONAL DATA FOR EMPLOYMENT/PLACEMENT SUITABILITY REVIEW Name: Last First M.I. Any alias(es)/former names (including maiden name): DOE OHR Last Revised: 01/01/2017 Former DOE Form(s): 90 DEPARTMENT OF EDUCATION Office of Human Resources Employee Background Check Unit P.O. Box 2360, Honolulu, HI Address: City: State: Zip: Sex: Male Female School/Office: Position(s): CONFIDENTIAL Date of Birth: Place of Birth:,, City State Country Other previous (identify most recent) or current DOE employment: SSN: II. STATEMENT OF PERSONAL BACKGROUND, EMPLOYMENT AND CRIMINAL HISTORY 1. Have you at any time been suspended, fired, terminated, dismissed, discharged or asked to resign from employment? YES NO 2. Have you at any time separated from military service under conditions other than honorable? 3. Have you at any time been arrested and/or convicted? If arrested, please specify what you were arrested for (attach separate sheet if necessary): If arrested, were you charged? If so please specify what you were charged with and the disposition (outcome) of the charge (attach separate sheet if necessary): 4. Have you at any time had a professional license or certification (for example, attorney, nurse, psychologist, teacher, school administrator, etc.) suspended, revoked, denied or not renewed? III. SWORN CERTIFICATE AND AUTHORIZATION TO OBTAIN FINGERPRINTS AND VERIFYING INFORMATION (See Responsibilities on back page) I swear that the above statements and information are true, complete and correct to the best of my knowledge and belief. I authorize the Hawaii State Department of Education to submit a set of my fingerprints to the Hawaii Criminal Justice Data Center (HCJDC) and the Federal Bureau of Investigation (FBI) for the purposes of accessing and reviewing state and national criminal history records that may pertain to me. I understand that my fingerprints will be retained by the HCJDC and the FBI for all purposes and uses authorized for fingerprint submissions, which may include participation in the state and national rap back program. I understand I have the right to challenge the accuracy and completeness of the results of my fingerprint-based criminal history record check, and that I may obtain a copy of my criminal history record by submitting fingerprints and fees directly to the HCJDC and/or the FBI. I understand that the procedures for obtaining a change, correction, or updating of my criminal history record are set forth in Title 28, Code of Federal Regulations, Section I authorize the Hawaii State Department of Education to obtain information from my current and past employers and references, and/or from any other source that may lead to the verification of the above-listed information; and waive the right to hold liable those persons for providing information or opinions which they believe to be accurate reflections of my personal background, employment history and/or criminal history. I agree that failure to declare, concealing, or falsifying criminal history, employment history, or background information to the department will constitute sufficient reason for immediate dismissal. I understand that my employment/placement with the Department of Education is conditional upon the completion of appropriate suitability checks and cannot begin (or continue) unless this statement is satisfactorily completed. Applicant/Trainee Legal Signature: Date: Distribution: Original - OHR, Employee Background Check Unit (Page 1 of 2)

3 IV. REVIEW BY PRINCIPAL, SUPERVISOR OR HIRING/PLACING AUTHORITY (See Screening Responsibilities below) Based on my screening of the information provided, and subject to the validation of criminal history record check, I am satisfied that this person will not pose a risk to the health, safety and/or well-being of children. (Attach additional information and/or explanatory report when applicable.) Principal/Supervisor/Hiring/Placing Authority Signature: Date: BACKGROUND: Chapter 7 of Title 8, Hawaii Administrative Rules, entitled "Public School Personnel: Criminal History Record, Employment History, and Background Checks," requires employees, applicants, and institute of higher education (IHE) trainees who work in close proximity to children to be of reputable and responsible character. According to this rule, the Department of Education (DOE) may conduct screening checks and may refuse to employ/place, and/or may terminate the employment of any employee, applicant, or IHE trainee who has a history, or background involving violence, alcohol or drug abuse, sex offense, offense involving children and/or any other circumstances which indicates that the individual being screened may pose a risk to the health, safety, and/or well-being of children. This confidential form is used by authorized officials to identify possible areas of concern about an employee's, potential employee's, or IHE trainee's criminal, employment and/or behavioral history. The DOE may terminate, or refuse to hire or place an applicant, employee, or IHE trainee who fails to complete this form, falsifies information and/or fails to cooperate fully with this screening process. SCREENING RESPONSIBILITIES (PRINCIPAL, SUPERVISOR OR HIRING/PLACING AUTHORITY): Form DOE OHR is completed by the employee, potential employee, or IHE trainee usually at the time of hiring/placing. Persons with hiring/placing and supervisory responsibility (principals, program coordinators, etc.) must ensure the proper completion and submittal of this form. They are also required to screen the completed form for each new employee prior to the effective start date or, at the time of form submittal. Additional clarifying information may be sought from this person if needed. When appropriate, former employers and/or other background references should be contacted to clarify or secure additional screening information. Appropriate action should be taken to delay, suspend, cancel or terminate the employment/placement of this person if information provided on this form or follow-up information indicates this person poses or may pose a possible risk to children. If such action is taken, a short explanatory report must be attached and submitted with the form. All reported information will be recorded on computer files for future references. Supervisors and other persons with hiring/placing authority may call and consult with the district personnel regional office or the EBC Office for assistance related to legal, contractual, and/or procedural issues. FORM DOE OHR PROCESSING: This form must be submitted to the appropriate district personnel regional or EBC Office for processing within 30 days of signature by the individual being screened, where a search will be conducted for prior criminal history information including fingerprint submittal if required. The Office of Human Resources (OHR) will notify the appropriate DOE supervisors if any further follow-up is required. Each employee is hired conditionally pending the results of this and other suitability checks including fingerprint screening against the FBI files. RESPONSIBILITIES: Employee, Potential Employee, or IHE Trainee Completes Form DOE OHR completely and accurately. Responds appropriately when requested to provide or clarify information. Each IHE trainee must complete and clear the criminal history background check before being placed in a DOE school. Supervisor or Hiring/Placing Authority Instructs the employee, potential employee, or IHE trainee to complete the Form DOE OHR Assures submittal of the form. Assures correct Social Security Number and picture identification. Reviews the completed form for areas of potential concern prior to the effective start date of employment/placement or at the time of form submittal. Follows up with prior employers and references as necessary. Takes appropriate action to prevent the employment/placement or continued employment of persons who may pose a risk to children. Submits Form DOE OHR along with other employment forms and reports as applicable to the district office/state office. Assistant/Complex Area Superintendent or Designee Reviews Form DOE OHR Creates and maintains records on the computer file. Assures confidentiality of information. Office of Human Resources Conducts a name based search for criminal history. Creates and maintains records on the computer file. Records responses from fingerprint screening. Follows up on any reports generated by the suitability check. Assures confidentiality of information. Updates computer files regarding any action taken on employees, applicants, or IHE trainees based on the background check results. OHR Use Only I acknowledge that I have read, understand, and agree to the FBI Privacy Act Statement. Applicant/Trainee Legal Signature: Date: CONFIDENTIAL Distribution: Original - OHR, Employee Background Check Unit (Page 2 of 2)

4 PRIVACY ACT STATEMENT Authority: The FBI s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L , Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records. 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. Additional Information: The requesting agency and/or the agency conducting the applicationinvestigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any systems(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s). Updated 9/9/2013

5 FBI FINGERPRINT INFORMATION FORM DOE-Office of Human Resources, EBC Unit 650 Iwilei Rd, Suite 300, Honolulu, Hawaii PICTURED ID AND SOCIAL SECURITY CARD ARE REQUIRED FOR FINGERPRINTING NAME: (As it appears on your Social Security Card): Last First Middle Name or Initial ALIAS: (Include maiden name or former married name(s) SOCIAL SECURITY NUMBER: - - DATE OF BIRTH: / / Month (XX) Day (XX) Year (XXXX) CITIZENSHIP: (Select One) [ ] U.S. [ ] OTHER-PLEASE SPECIFY SEX: (Circle One) MALE FEMALE RACE: (Circle One) C Chinese K Korean T - Tongan F Filipino B Black W White H Hawaiian O - Other X - Unknown I Native American P - Hispanic J Japanese S - Samoan HEIGHT: feet inches WEIGHT: pounds COLOR OF EYES: (Circle One): Black, Blue, Brown, Green, Gray, Hazel, Maroon, Multicolored, Pink, Unknown COLOR OF HAIR: (Circle One): Black, Blonde, Brown, Gray, Red, Sandy, White, Bald, Blue, Green, Orange, Purple, Pink, Unknown PLACE OF BIRTH: (Specify State if in United States. If other, please specify country) HOME ADDRESS: Mailing Address (If different from address below) Physical Address Not P O Box PHONE NUMBER: POSITION TITLE: SCHOOL/OFFICE: ohrfpinfo rev