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California Department of Public Health Viral and Rickettsial Disease Laboratory Specimen Submittal Form Patient s mailing address (including Zip code) Patient s last name, first name Age or Sex (circle):
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hi I'm going to guide you through the CD pH 325 criminal record clearance submissions for the CD pH 325 is a one-page form this form is used to determine the background clearance of certain direct care employees including licensee personnel for intermediate care facility development to lead disabled ICF DD intermediate care facility developmentally disabled - habilitative ICF DD - H intermediate care facility developmentally disabled - nursing ICF DD - in and home health agency HH a the California Health and Safety Code division - chapter 2 section 12 65 05 - a B requirements for licensed intermediate care facilities specifically ICF DD ICF DD - H and ICF DD - in states that the criminal record clearance shall require the applicant to submit electronic fingerprint images and related information of the facility administrator or manager and any direct care staff or any other adult living in the same location to the department of justice applicants shall be responsible for any cost associated with capturing or transmitting the fingerprint images and related information the criminal record clearance shall be completed prior to direct staff contact with the residents of the facility and criminal record clearance shall be complete when the department has obtained the person's criminal record information from the department of justice and has determined that he or she is not disqualified from engaging in the activity for which clearance is required when completing this form list all personnel of ICF DD ICF DD - H and ICF DD - in the list must include but is not limited to the following individuals all current and future direct care employees including licensee personnel including owners onboard officers directors LLC managers members administrator any adults living at the facility and consultants who are directly providing program andor nursing services to clients here's a tip if the consultants are independent contractors and not an employee of the facility they are exempt from these fingerprints however the applicant must submit a written statement to that effect the following criteria exempts consultants from background checks one is employed as a consultant and acts as direct care staff - is a registered nurse licensed vocational nurse physical therapists occupational therapists or speech-language pathologists 3 has obtained a criminal record clearance as a prerequisite to holding a license or certificate to provide direct care services for has a license or certification to provide direct care services that is in good standing with the appropriate licensing or certification board 5 is providing time limited specialized clinical care or services and 6 is not alone with a client the California Health and Safety Code Division - chapter 8 section 17 281 a2a states the following requirements regarding criminal record clearance for a home health license to qualify for a home health agency license the following requirements shall...