Fill in a Valid Illinois Waiver Template

The Illinois Waiver Form is an application used by healthcare workers seeking a waiver from certain disqualifications to continue or gain employment. This form collects essential personal and professional information to facilitate a background check and ensure compliance with state regulations. Filling out this form correctly is important for a smooth processing experience, so start your application by clicking the button below.

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The Illinois Waiver form serves as an essential document for individuals seeking to work in healthcare settings across the state, ensuring that all necessary qualifications are met before employment. This application, issued by the Illinois Department of Public Health, requires applicants to provide detailed personal information, including their name, address, social security number, and criminal history authorizations. Importantly, applicants must consent to a fingerprint-based background check conducted by the Illinois State Police. The form also requests specifics regarding the individual’s race, sex, height, and eye color, although this data is strictly for identification purposes and will not impact employment decisions. Moreover, the form includes sections where candidates must disclose their work history, any previous certifications as a nurse aide or assistant, and any criminal convictions or administrative findings related to abuse or neglect. Supporting documents, such as proof of rehabilitation or employment references, can be submitted alongside the completed application. After submission, the applicant will receive a Livescan Request Form, facilitating the fingerprinting process at designated locations. Overall, this waiver form is not just a bureaucratic procedure; it plays a vital role in maintaining safety and care standards in Illinois’s healthcare facilities.

Illinois Waiver Example

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 217-785-5133 Fax 217-524-0137 E-mail [email protected]

All information requested on this application must be provided before you will be considered for a waiver. Type or print clearly in ink.


	Today’s Date
Name		(First, Full Middle and Last)
Address		(Street, Apartment #, P. O. Box)
		(City, State, ZIP Code)

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 fingerprint-based criminal history records check submitted as a fee applicant inquiry requested by the Department. I further authorize the Illinois State Police (ISP) to release information relative to the existence or nonexistence of any criminal record which it might have concerning me to the requestor solely to determine my suitability for employment or continued employment. I further authorize any agency that maintains records relating to me, including but not limited to the Federal Bureau of Investigation or a local unit of government, to provide same on request to the ISP or the Department. I certify that the ISP and any agency, including the Department, their employees or officers who furnish this information shall be held harmless from any and all liability which may be incurred as a result of releasing such information. I further acknowledge that a health care employer shall not be liable for the failure to hire or retain an applicant or employee who has been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

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		Height		Eye Color		Date of Birth
(Enter a letter from below):

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.

Employer	Date Started	Separation Date

Employer’s Address, City, State, ZIP Code

Employer	Date Started	Separation Date

Employer’s Address, City, State, ZIP Code

Other states where you have lived or worked

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.
Were you required to pay a fine in connection to a disqualifying offense?				Yes	No	If yes, you must provide

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 up-to- date on the schedule.

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

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

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

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.

Signature

Date

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.

Signature

Date

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.

Click for Illinois Waiver File

File Breakdown

Fact Name	Details
Governing Law	The Illinois Waiver form is governed by the Health Care Worker Background Check Act, 225 ILCS 46/25.
Purpose	This form is used to apply for a waiver to work in health care settings in Illinois.
Required Information	Applicants must provide personal details, including name, address, Social Security number, and work history.
Criminal History Check	By signing the form, applicants authorize a fingerprint-based criminal history records check.
Liability Statement	The form includes a clause that protects the Illinois Department of Public Health from liability in connection with the release of information.
Identification Information	Personal details such as race, sex, height, eye color, and date of birth are requested for identification purposes only.
Submission Process	Completed forms should be mailed to the Illinois Department of Public Health for processing.

Guide to Using Illinois Waiver

After completing the Illinois Waiver form, you will need to send it to the Illinois Department of Public Health for processing. Make sure all required information is filled out clearly. Once your application is processed, you will receive a Livescan Request Form to facilitate the fingerprinting procedure. Follow the steps below to fill out the form accurately.

Start by writing today’s date in the designated field.
Enter your full name, including your first name, middle name, and last name.
Provide your complete address, including street, apartment number (if applicable), city, state, and ZIP code.
If you have a maiden name or any other names you have used, include them in the appropriate field.
Fill in your telephone number where you can be contacted.
Enter your Social Security number, as it is required.
Indicate your sex by checking the appropriate box for either Male or Female.
Choose your race from the options provided and write it in the specified space.
Specify your height, eye color, and date of birth in the corresponding fields.
Document your entire work history, starting with your current employer. If necessary, use additional pages to provide complete information.
If applicable, answer whether there was an involvement of alcohol or drugs in any offenses and provide necessary rehabilitation documentation if needed.
Answer whether you were required to pay a fine in connection with any disqualifying offense, and include proof of payment if applicable.
If you were on probation or parole, confirm whether you completed it and provide proof of completion.
State whether you have been certified as a nurse aide/assistant in another state and provide related certification details.
If your name has changed, attach legal documents that support the name change, along with a copy of your identification.
Indicate if you ever had an administrative finding of abuse, neglect, or theft and specify the state in which it was issued.
Answer questions regarding past criminal convictions and provide circumstances around each offense if applicable.
Sign and date the application at the bottom, certifying that all information is true and correct.
If applicable, a parent or guardian must also sign for individuals younger than 17.

After completing the form, mail it to the Illinois Department of Public Health as instructed. Ensure that all documents are included before sending. Prepare for the next steps once the department processes your application.

Get Answers on Illinois Waiver

What is the Illinois Waiver form?

The Illinois Waiver form is a document required by the Illinois Department of Public Health for individuals applying for a waiver related to health care worker positions. This form collects personal information, work history, and disclosures regarding criminal records, if any. It is necessary for determining an applicant's suitability for employment in the healthcare sector.

Who should complete the Illinois Waiver form?

Any individual seeking employment as a health care worker in Illinois must complete the Illinois Waiver form. This includes applicants for positions such as nurse aides, assistants, and other roles that require a background check as part of the hiring process.

What information is required on the form?

The form requires various pieces of information, including:

Full name and address
Social Security number
Work history
Criminal history details
Personal identifiers, such as race, sex, height, and date of birth

All information must be provided clearly to be considered for a waiver.

Yes, providing your Social Security number is mandatory as per Illinois law. This information is used strictly for identification purposes and to help process the waiver application.

What happens if I have a criminal record?

If you have a criminal record, you must disclose it on the form. The Department will assess your criminal history to determine your eligibility for employment. Additionally, if certain conditions apply, such as successful completion of a rehabilitation program or payment of fines, you must provide proof of compliance.

How do I submit the Illinois Waiver form?

To submit the form, complete it with all the required details and mail it to the Illinois Department of Public Health, specifically to the Health Care Worker Registry at the following address:

Illinois Department of Public Health
Health Care Worker Registry
525 W. Jefferson St., Fourth Floor
Springfield, IL 62761

Upon receipt of your application, the Department will send you a Livescan Request Form to facilitate the fingerprint collection process.

Can I appeal a denial of my waiver application?

Yes, if your waiver application is denied, you have the right to appeal the decision. It's important to review the denial communication for specific instructions on the appeals process and any required deadlines.

What should I do if I have questions about the form?

If you have questions regarding the Illinois Waiver form or the application process, you can contact the Illinois Department of Public Health at the following:

Phone: 217-785-5133
Fax: 217-524-0137
Email: [email protected]

Common mistakes

Filling out the Illinois Waiver form can feel like a daunting task, but avoiding common mistakes can simplify the process significantly. One frequent error is failing to provide all required information. Every piece of information requested is crucial for processing your waiver. Leaving sections blank or omitting details can lead to delays or even denials of your application.

Another common mistake involves handwriting that is unclear or difficult to read. Clarity is key. When filling out the form, it is essential to type the information or print it neatly in ink. Illegible handwriting can create confusion, which might result in misinterpretation of important details.

People often forget to include their social security number, thinking it is optional. In reality, the law requires this information. Failing to provide your social security number means that your application will be considered incomplete, which can hinder your chances of receiving a waiver in a timely manner.

Additionally, individuals sometimes overlook the importance of including a complete work history. The form requests a detailed employment record, and applicants may mistakenly think a simple list suffices. Make sure to include specific dates and addresses of previous employers to ensure that your work history is thoroughly documented.

A key oversight involves understanding the rehabilitation requirements tied to disqualifying offenses. If you were ordered to partake in a program and have successfully completed it, it is essential to provide proof. Some applicants may assume this step is unnecessary, leading to potential issues with their application.

Another potential pitfall is the treatment of document attachments. If you need to submit copies of certifications or legal documents for name changes, make sure to include them. Failing to attach required documentation can impede the progress of your application, prolonging the waiting period for your waiver.

Some people may also forget to double-check their consent signatures. Providing a signature where indicated is not just about formality; it signifies your consent for background checks. An absent or incorrect signature can result in delays in processing.

Furthermore, it is crucial to review the information regarding previous administrative findings. Ignoring this part can lead to miscommunication. If any such findings exist, you must disclose them, even if they were not serious offenses.

Finally, one mistake that can easily be overlooked is not keeping a copy of your application. It is wise to retain a copy for your personal records, as this could serve as a reference if there are any questions or if additional information is required. Preparing properly by avoiding these common mistakes can make the application process go more smoothly.

Documents used along the form

When applying for the Illinois Waiver form, several additional documents and forms may be required to ensure a smooth process. Each serves a vital purpose in verifying your qualifications and suitability for employment in the healthcare field. Below is a list of common documents you might need alongside the waiver application.

Criminal History Records Check: This document shows a detailed account of any criminal activity. It is essential for confirming eligibility for healthcare employment.
Livescan Request Form: Issued by the Illinois Department of Public Health, this form is used for the collection of fingerprints needed for background checks.
Employment Reference Letter: A letter from a previous employer attesting to your work ethic and capabilities. This can enhance your application by demonstrating past performance.
Character Reference Letter: This letter typically comes from a colleague or community member who knows you well. It highlights your character traits and professional demeanor.
Proof of Rehabilitation Program Completion: If applicable, this document verifies that you have successfully completed any required rehabilitation following a disqualifying offense.
Certification Verification: If you have been certified as a nurse aide/assistant in another state, you’ll need to provide proof. This includes your certification number and any associated documents.
Documentation of Name Changes: If your current name differs from what's on your identification, include legal documents (like a marriage certificate) that justify the change.

Collecting these documents will help streamline your waiver application process. Being prepared with the necessary paperwork can save time and ensure you meet all requirements for employment in the healthcare industry.

Similar forms

Job Application Form: Like the Illinois Waiver form, job applications often require personal information and authorization for background checks. Both documents emphasize the importance of honesty regarding past conduct.
Background Check Consent Form: This document, similar to the Illinois Waiver, allows potential employers to conduct a criminal history check. It outlines the scope of the background investigation, similar to the records check authorization in the waiver.
Medical License Application: Much like the Illinois Waiver, a medical license application involves personal details and must include authorizations for background checks. Both applications aim to establish the applicant's fitness for a position in the health field.
Professional Certification Application: Both documents request a history of criminal offenses and require individuals to disclose relevant past events to determine eligibility for certification in a profession.
Parole Application: Just as the Illinois Waiver assesses criminal history, parole applications often include sections where individuals outline their past offenses and rehabilitation efforts, aiming to demonstrate readiness for reintegration.
Licensing Form for Caregivers: Similar to the Illinois Waiver, forms for licensing caregivers require personal information and often include detailed questions about an applicant’s criminal history and rehabilitation.
Volunteer Application: Like the Illinois Waiver, volunteer applications frequently include sections to gather background information to ensure the safety of populations served, especially vulnerable groups.
Student Admission Application for Health Programs: Both the Illinois Waiver and related applications for health programs may seek information about criminal history, emphasizing safety in a healthcare education context.
Child Care Background Check Form: Similar to the Illinois Waiver, these forms also require detailed personal information and consent for background checks to protect the welfare of children.

Dos and Don'ts

Do's:

Provide all requested information accurately, as incomplete forms will delay processing.
Print clearly using ink, ensuring that all information is legible.
Attach any required documents, such as proof of rehabilitation or certification, to support your application.
Sign and date the application to confirm that all details are true and correct.
Mail the completed form to the specified address promptly to avoid any delays.

Don'ts:

Do not leave any sections of the form blank; even small details are important.
Avoid using pencil or illegible handwriting, as this may result in processing issues.
Do not submit the application without the necessary supporting documents if applicable.
Do not forget to keep a copy of the completed form for your records.
Refrain from providing false information; inaccuracies can jeopardize your application and eligibility.

Misconceptions

Below are five common misconceptions about the Illinois Waiver form that people often believe. Understanding these will help clarify the process and requirements associated with the form.

Misconception 1: The Illinois Waiver form can be submitted without providing complete information.

In fact, the application requires all requested information to be filled out in full before it can be processed. Incomplete forms will delay the review and approval process.

Misconception 2: Submitting my Social Security number is optional.

This is incorrect. Providing your Social Security number is mandatory as required by law. It is essential for the identification and processing of your application.

Misconception 3: I can omit previous criminal offenses if they have been expunged or sealed.

When filling out the form, you are instructed not to include offenses that have been expunged, sealed, or are juvenile adjudications. However, all other relevant convictions must be disclosed.

Misconception 4: Providing proof of rehabilitation is not necessary if I was convicted of a disqualifying offense.

This is misleading. If you were required to complete a rehabilitation program as part of a conviction, you must provide proof of successful completion along with your application.

Misconception 5: The application process is the same regardless of my previous employment in other states.

This is false. If you have worked or lived in other states, you are required to provide information regarding your employment there. This helps the Illinois Department of Public Health obtain a comprehensive background check.

Key takeaways

Key Takeaways for Filling Out and Using the Illinois Waiver Form:

Complete all sections of the form. Missing information may delay your application process.
Use clear handwriting if you are filling it out by hand. Typed forms are preferable.
Provide your Social Security number; it is required by law for identification purposes.
Include a full work history or attach your resume. Start with your most recent employer.
If applicable, furnish proof of any rehabilitation programs or fines associated with disqualifying offenses.
Mail the completed form to the specified address to initiate the process; expect a Livescan Request Form in return.