$(document).ready(function() { // validate signup form on keyup and submit $("#submitform").validate({ rules: { Applicants_Name: "required", Individuals_Name: "required", Individuals_Name_: "required", Employer_Name: "required", I_request_that_my_FMSA_obtain_a_current_Criminal_Conviction_History_Check_of_the_applicant_from_DPS: "required", Date_of_DPS_Check: "required", secode: "required" }, messages: { Applicants_Name: "Required", Individuals_Name: "Required", Individuals_Name_: "Required", Employer_Name: "Required", I_request_that_my_FMSA_obtain_a_current_Criminal_Conviction_History_Check_of_the_applicant_from_DPS: "Required", Date_of_DPS_Check: "Required", secode: "" } }); $('#Date_of_Birth,#Date,#Date_of_DPS_Check,#Date_FMSA_staff_notified_employer,#Date_disseminated_by_FMSA,#Date_report_was_destroyed,#Date_employer_notified_FMSA_of_hiring_decision').datepick({ yearRange: "1970:2014", showTrigger: 'Select date' }); $("#submitform").submit(function(){ if($(this).valid()){ self.parent.$('html, body').animate( { scrollTop: self.parent.$('#myframe').offset().top }, 500 ); } }); $("#submitform").submit(function(e){ if($(this).valid() && grecaptcha.getResponse() != ""){ $(".loader").css('visibility', 'visible'); self.parent.$('html, body').animate( { scrollTop: self.parent.$('#myframe').offset().top }, 500 ); } else { if(grecaptcha.getResponse() == "") { var $recaptcha = document.querySelector('#g-recaptcha-response'); if($recaptcha) { $recaptcha.setAttribute("required", "required"); } $('.g-recaptcha').addClass('errors').attr('id','recaptcha'); var $test = $('#recaptcha div:first').css('width','304px'); if($test){ $test.addClass('rec'); } } else { /* alert("Thank you"); */ } e.preventDefault(); } }); });
* = Required Information
Applicant is a person being considered as a service provider (employee or independent contractor [when required]).

Section I - Applicant Authorization/Acknowledgment (Applicant must complete this section)

I, *, give my permission to check for a criminal conviction history, to check the required registries annually, and to check the state and federal lists of individuals and entities excluded from participation in Medicaid(LEIE)monthly as part of my application as a service provider through the Consumer Directed Services (CDS) option. I also understand that a criminal conviction or a registry listing that prohibits a person from employment in a health care setting in the state of Texas may prohibit my employment.

I understand that I must not provide services for payment until the required criminal history and registry checks are conducted, the employer and Financial Management Services Agency (FMSA) review the results and determine that I can be paid for services, and this form is signed by the FMSA.
Applicant Information Required by the Texas Department of Public Safety (DPS)
Section II - Criminal Conviction History Check and Registry Verification Process (Employer must complete this section.)
Criminal Conviction History Check (Check each box to certify agreement):

I request that my FMSA obtain a current Criminal Conviction History Check of the applicant from DPS. I authorize the FMSA to be reimbursed for the cost of obtaining the DPS Criminal Conviction History Check and if I request the report, the cost of sending the report from my budgeted funds.
I understand that if I request the report, the FMSA must send it to me through a secure method, DPS approved encrypted software or certified mail.
I understand that all criminal records and reports obtained by my FMSA, and the information they contain, are confidential information.
I understand that all DPS criminal history information reports must be destroyed five days after I make the hiring decision. Paper records need to be shredded, pulped or burned. For electronic records, destroying the media or using specialized software to copy over the data are acceptable methods.
I understand that sharing of criminal history information with any person or agency may be prosecuted as a Class A Misdemeanor.
Registry Check
I request that my FMSA obtain the applicant's status with the Employee Misconduct Registry and the Nurse Aide Registry initially and annually.
I understand that my FMSA will screen the applicant initially and monthly using both the state and federal lists of excluded individuals and entities(LEIE).
I also understand that the applicant cannot provide services and cannot be paid with program funds until the criminal history and registry checks are completed and my FMSA has notified me that the applicant meets the qualifications.
Verbally Encrypted email Certified mail
Section III - Criminal Conviction History and Registry Check Results DPS Criminal Conviction Criminal History Check
Yes No
Verbally
Encrypted email
Certified mail
Did not request report - sent Form 1725
Yes No