Disclosure and Consent for Background Verification Report

DISCLOSURE AND CONSENT FOR BACKGROUND REPORT
AND CRIMINAL OFFENDER RECORD INFORMATION (CORI) CHECK
(For Responsible Adults under the Harvard Policy for the Safety & Protection of Minors)

This form, which you should read carefully, has been provided to you because Harvard University ("Harvard") may request Consumer Reports and/or Investigative Consumer Reports from a consumer reporting agency. Harvard will use any such report(s) solely for purposes related to your eligibility for employment or assignment. In addition, Harvard is registered under the provisions of M.G.L. c. 6, §172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, volunteers, and contractors.

Consumer Reports or Investigative Consumer Reports will be obtained from HireRight, Inc. ("HireRight"), located at 2100 Main Street, Suite 400, Irvine, CA 92614. They can be contacted at 866-521-6995. Any such reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: credit reports, social security number, criminal records checks, public court records checks, including civil, driving records, educational records, verification of employment positions held, personal and professional references, licensing, certification, etc. The information contained in these reports may be obtained by HireRight from private or public record sources, including sources identified by you in your application or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances. If Harvard requests an investigative consumer report, you have the right, upon written request, to a copy of the report.

By signing below, you acknowledge that you understand that your service as a Responsible Adult in a minors program with Harvard is conditioned upon the satisfactory results of any Consumer Reports or Investigative Consumer Reports regarding you. You understand that if the report(s) is (are) not satisfactory, as determined by Harvard in its sole discretion, you may not be permitted to serve as a Responsible Adult in a minors program; moreover, you may be denied employment or your employment with Harvard may be terminated.

You are being given a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. section 1681(g)(c). You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights by contacting HireRight.

If you are a California applicant, employee, or contractor, please also note:

Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight’s offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. HireRight has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.

□ California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report.

CONSENT

CORI CHECK. As a prospective or current employee, volunteer, or contractor, I understand that a CORI check may be submitted for my personal information to the Massachusetts Department of Criminal Justice Information Services (DCJIS). By my signature below, I hereby acknowledge and provide permission to Harvard to submit a CORI check for my information to the DCJIS. I understand that my authorization shall be valid for one year of my signing this form, or until the conclusion of my employment (should I become employed) or assignment, whichever comes first. I may withdraw this authorization at any time by providing Harvard with written notice of my intent to withdraw consent to a CORI check. Harvard may conduct subsequent CORI checks within one year of the date this form was signed by me; provided, however, that Harvard must first provide me with written notice of the CORI check.

BACKGROUND REPORT. I have carefully read and understand this Disclosure and Consent form and, by my signature below, consent to the release of Consumer and/or Investigative Consumer Reports, as defined above, to Harvard in conjunction with my employment or application for employment or assignment as a Responsible Adult. I further understand that any and all information contained in my application or otherwise disclosed to Harvard by me before, during or after my employment or assignment, if any, may be utilized for the purpose of obtaining the Consumer Reports or Investigative Consumer Reports requested by Harvard. I understand that if I am hired or assigned to serve as a Responsible Adult, Harvard may request a Consumer Report and/or an Investigative Consumer Report about me, as defined above, for these purposes during the course of my employment, assignment, or enrollment. I understand that my consent will apply throughout my employment, assignment, or enrollment, to the extent permitted by law, unless I revoke or cancel my consent by sending a signed letter or statement to Harvard at any time. I hereby release and agree to hold harmless Harvard, its past, present, and future officers, agents, employees and members of its governing boards, from any and all liability, claims or damages that may directly or indirectly result from the request for, or use, release, or disclosure of any of the above-referenced information. I also authorize any individuals, present or former employers, schools and colleges, credit bureaus, criminal investigation bureaus, sex offender registration bureaus, state agencies and any other entities that may possess information regarding me or that may be custodians of records relating to me, to release all information requested, and I hereby release those sources from liability for doing so. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by Harvard.

By signing this form I hereby give my consent to Harvard University to conduct the background report and CORI check as described above. I further represent and confirm that the information provided below is accurate and complete.

Last Name ______First ______Middle ______

Signature ______Date ______

SELF-DISCLOSURE OF CRIMINAL HISTORY. I hereby agree to disclose to Harvard any and all arrests or convictions involving crimes of a violent or sexual nature, and to immediately disclose to Harvard any and all such arrests or convictions occurring at any time during the course of my employment, assignment or enrollment after the date I sign this form.

[__] I have no arrests or convictions involving crimes of a violent or sexual nature.

[__] I have the following arrests and / or convictions involving crimes of a violent or sexual nature:

The following information is required for conducting reference and background checks. It will not be used for any unlawful purpose.

______

Last Name First Name Middle Name Suffix

Other names by which you have been known: ______

Date of Birth: ______Place of Birth: ______

Last six digits of your Social Security No.: ______

Height: ____ft. ____in. Eye Color: ______

Driver’s License or ID Number: ______State of Issue: ______

______

Mother’s Full Maiden Name Father’s Full Name

Your current and former addresses:

______

Street Number & Name City/Town State Zip

______

Street Number & Name City/Town State Zip

______

For positions requiring a DMV/MVR screen:

Do you have a valid Driver’s License? ______Yes ______No

License Number ______State of Issue______

The above candidate personally appeared and proved to me to be the person whose name is signed on this form by presenting the following forms(s) of government-issued identification:[1]

______

Verified by: ______

(Printed name of HR Representative)

______

Signature of HR RepresentativeDate

NOTE: If an HR representative is unable to verify the candidate’s identity and signature in person, the candidate may sign this CORI Acknowledgement Form before a Notary Public. In that case, the following should be substituted for the above HR Representative authentication.

Authentication of Signature by Notary Public

On this _____ day of ______, 20____, before me, the undersigned notary public, personally appeared ______(name of candidate), who proved to me through satisfactory evidence of identification, which was ______, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.

______

Notary Public

My Commission Expires: ______

1

[1] Acceptable forms of identification include a state-issued driver’s license or identification card with a photograph, a passport, or a military identification.