Health Care Program Disclosure of Criminal Background

The health related career you are pursuing requires disclosure of criminal background to obtain a license to practice. Past felony or misdemeanor offenses may not necessarily prevent you from obtaining a license to practice but that is determined by New York State.

During your studies at GCC, some clinical sites may conduct background checks on students prior to allowing participation in clinical experiences.

You are required by GCC policy to disclose any criminal background information for admission into this health related career program. Undisclosed criminal history that is later revealed through a clinical background check will result in immediate dismissal from the program.

If you disclose a criminal history, you will be asked to provide additional information and meet with the colleges Ex-Offender Review Committee. They will determine if admission into this program will be allowed.

Applicant Information

Full Name(Required)

Email(Required)

Phone(Required)

Disclosures

1. Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any court?(Required)

Yes

2. Are criminal charges pending against you in any court?(Required)

Yes

3. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?(Required)

Yes

4. Are charges pending against you in any jurisdiction for any sort of professional misconduct?(Required)

Yes

5. Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?(Required)

Yes

NOTE: If you answer “Yes” to any questions numbered 1-5, please provide a detailed explanation below.

Affirmation

By filling in your name, you affirm that the information you have provided is true to the best of your knowledge at the time this form is submitted. You may be required to sign a physical document before completing the review process.

Applicant Name(Required)

Fill in your name as you would sign it.

Date of Affirmation(Required)

{date_month}

{date_day}

{date_year}

Disclosure Details

Date of conviction:

Date of incarceration (if incarcerated):

Date of release from incarceration (if incarcerated):

Incarceration facility (location):

Nature of the charge and conviction:

Any active probation or parole conditions including names and address of your parole officer:

Any other information or explanation regarding the above or other criminal or professional misconduct charge:

Name

This field is for validation purposes and should be left unchanged.

Health Care Program Disclosure of Criminal Background

Applicant Information

Disclosures

Affirmation

Disclosure Details

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