Withhold from Public Disclosure – Confidential
Trustworthy & Reliability Determination Form
The State of California modified the University of California, Riverside radioactive materials license which requires a determination of trustworthiness and reliability for each individual having unescorted access to certain quantities of radioactive materials. This form establishes that determination.
First Name/ Last Name
/ Employee/Student ID#
Title
/ Department
/ Research Group
Lab Location
/ Lab Phone Number
/ Email Address
Questions for the Evaluating Official
1. Does the employment history at UCR indicate the individual is trustworthy and reliable?
(See “Indicators” on back) (If no, contact the RSO for further assistance.)
2. Describe the method you used to review the individuals employment history at UCR. (See “methods” on back)
3. Has this individual been employed by UCR for at least three years? (If yes, skip questions 4 and 5)
4. Please verify the following:
a. Pre-UCR Employment History (within last three years)
Employer / Dates Employed
Name of Contact / Contacts Position/Title
b. Education
Employer / Dates Employed
Name of Contact / Contacts Position/Title
c. Personal References
Name
/ Relationship
/ Date Contacted
Name
/ Relationship
/ Date Contacted
5. Describe your attempts to independently corroborate the information in question 4. (See “attempts” on back)
Evaluating Official
By your signature below, you are attesting that to the best of your ability you have established that the above named individual is trustworthy and reliable and that there is no outstanding evidence present to suggest that they should be refused unescorted access privileges. Please contact the RSO at (951) 827-5746 if for any reason you determine the individual should not be considered trustworthy or reliable.
Print Name (first/last): / Title:
Signature: / Date:
Employee ID: / DOB (MM/DD/YYYY):
EH&S USE ONLY
Print Name (first/last): / Title:
Signature: / Date:
Withhold from Public Disclosure – Confidential
For the purpose of this evaluation, the definition of trustworthy and reliable is an individual who is considered consistently dependable in judgment, character, performance, and does not constitute an unreasonable risk to the public health and safety.
The following are some negative indicators that you may want to consider:· Impaired performance attributable to psychological or other disorders.
· Conduct that warrants referral for criminal investigation or results in arrest or conviction.
· Indication of deceitful or delinquent behavior.
· Attempted or threated destruction of property or life.
· Suicidal tendencies or attempted suicide.
· Illegal drug use or the abuse of legal drugs.
· Alcohol abuse disorders.
· Recurring financial irresponsibility.
· Irresponsibility performing assigned duties.
· Inability to deal with stress, or having the appearance of being under unusual stress.
· Failure to comply with work directives.
· Hostility or aggression toward fellow workers or authority.
· Uncontrolled anger, violation of safety or security procedures, or repeated absenteeism.
· Significant behavioral changes, moodiness or depression.
These indicators are not meant to be all inclusive or intended to be disqualifying factors, but also you may consider extenuating or mitigating factors in the determinations.
The following are examples of methods used to review employment history at UCR:
1. I spoke with Jane Doe from the Department of Human Resources who reviewed this individual’s personnel file and disclosed that there was no documented evidence that suggested this individual is not trustworthy or reliable.
2. I reviewed this individual’s personnel file and found no documented evidence suggesting this individual is not trustworthy or reliable.
The following are examples of attempts to obtain corroborating information:
Note: Information previously obtained during the Human Resources hiring process may be used to support the determination without having to re-verify that information.
1. I independently verified the phone number for the Human Resources department of Company XYZ and spoke to Mr. John Doe who verified this individual’s employment status.
2. I analyzed documentation and oral information. I interviewed Mr. John Doe from Student Affairs, and he verified this individual’s transcripts, financial aid application, enrollment application, and student visa were in order.
3. I confirmed through Human Resources that this individual has been deemed employable following a criminal background check.