MN Department of Human Services Background Check Form

You have been hired to work in an area of Regions Hospital that is licensed by the Minnesota Department of Human Services (DHS). As an individual that may have direct patient contact in your role, we are required to initiate a background study though DHS to remain compliant with licensing. Please fill out the information below:

IMPORTANT: The information listed below must match the identification you provide to be fingerprinted otherwise you will not be able to be fingerprinted.

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* 1. PERSONAL INFORMATION

First Name

Middle Name

Last Name

Permanent Physical Address

City

State

Zip Code

Email Address

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* 2. Date of Birth (Month/Day/Year)

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* 3. Race

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* 4. Sex

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* 5. Eye Color

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* 6. Hair Color

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* 7. Height (feet and inches)

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* 8. Weight (lbs)

500

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Drivers License, State ID or Passport Number

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* 10. Place Of Birth

If Born Outside of the United States: Please list the Country you were born in the text below (Ex: Ethiopia)

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* 11. New Job Title

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* 12. Facility

Regions

RHSC

Hovander House

Safe House

Afton

HPMT