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LINN-BENTON COMMUNITY COLLEGE
CRIMINAL BACKGROUND CHECK (CBC) RELEASE AGREEMENT
NAME __________________________ PROGRAM OF STUDY
Please Print
Social Security # E-MAIL ADDRESS: _____________________________
Required
STUDENT ADDRESS: ___________________________________________________________________
Street City State Zip Code
I authorize Linn-Benton Community College (LBCC) to use any of my personal information required to process my CBC for
admission to my chosen program. I authorize LBCC to use my SSN to complete a verification of non-exclusion using the federal
Health & Human Services Office of Inspector General’s (HHS OIG) secure database.
I understand the reports may include specific and personal information about my character, general reputation and background. I
authorize LBCC to report whether my background checks are “clear” or “not clear” (meaning the reports show reportable incidents,
or exclusions) to external clinical or practicum sites. I understand this will be done in order to place me in a clinical practicum or
work experience situation. I understand that this is the sole use and purpose of this information and that LBCC will otherwise
keep this information confidential in compliance with rules regarding the privacy of student records, Fair Credit Reporting Act and
other applicable regulations. I also understand that if my CBC is “not clear,” I may appeal the LBCC determination. I understand
that any exclusion found on the HHS OIG report will disqualify me from admission and there is no appeal.
I understand and acknowledge that these background checks are not being used to determine my general admission to LBCC,
they do not guarantee eligibility for clinical placement, licensure or employment in my chosen field of study. If the CBC results
prevent me from being placed in a clinical or practicum experience, I acknowledge that I will not be admitted to the program and
my space will be given to the next eligible applicant. I agree to run a true and accurate report based on my personal history that
will include all counties I have resided in during the last 7 years. I acknowledge that some licensing boards, or employers, may
require more extensive reports.
I acknowledge and agree that I have a responsibility to self-disclose and notify the program coordinator in writing if my criminal
background or HHS OIG status changes at any time between this date and the date of my program completion. I understand that
any falsification, misrepresentation, or omission of required information may result in immediate removal from the program and
disciplinary action. If admitted and subsequently excluded by the HHS OIG or convicted of a crime that will disqualify me from
clinical placement or licensure, I understand that I will be disqualified from continuing in the program.
If I am charged with a crime, but not convicted, I may be subject to significant disruption in my clinical placement (and overall
progression through the program) if the clinical site requires that the charge be resolved as a condition of continuing in that
placement. The college cannot control the factors a clinical site may use to restrict a student from its premises. It may be
necessary for LBCC personnel to consult with clinical site personnel on matters related to past, or pending, criminal charges; your
signature below is your consent to such consultations.
I have read and understand this request for information and the attached summary of rights under the Fair Credit Reporting Act
and agree to hold LBCC, its officers, agents and employees harmless from any liability resulting from the use of the information
requested. The criminal history background information is compiled from and processed by various third party sources through
ChoiceTrust and the HHS OIG. LBCC does not guarantee, or assume any responsibility for the accuracy of the information
obtained from ChoiceTrust, the HHS OIG, or other sources, and shall not be liable for any losses or injuries now or in the future
resulting from or relating to the information provided by them. By my signature I agree to the above terms.
______________________________________________________________________________________
Student Signature Date
Have you completed a criminal background check for LBCC in the last 12 months?
IF YES, STOP, see Dorothy Fisk before completing this process
RETURN THIS FORM TO DOROTHY FISK, WILLAMETTE HALL WH-124, LBCC
Revised 6/11//07
LINN-BENTON COMMUNITY COLLEGE
CRIMINAL BACKGROUND CHECK PROTOCOL FOR STUDENTS
IMPORTANT! READ THESE DIRECTIONS COMPLETELY BEFORE YOU LOGON.
1. Have you completed a criminal background check for LBCC in the last 12 months?
IF YES, STOP and contact Dorothy Fisk before completing this process.
2. Have your credit or debit card ready before you begin.
3. WRITE A LIST of ALL Counties and the State they were in that you have resided in during the last 7 years.
4. Have your PREVIOUS ADDRESS if you have lived at your current address less than 6-months.
5. YOU MUST HAVE AN EMAIL ADDRESS to receive this report.
6. Be sure you read all on-screen instructions, disclaimers and authorizations.
7. This is a technical process that sometimes takes 3-5 days to fully complete.
8. If you encounter PROBLEMS running your report, click on CONTACT US (bottom of screen) and follow directions.
READY TO START? This portion should take about 15-20 minutes to complete.
1. Log on to http://www.choicetrust.com
2. Click on the Pre-Employment Self-Check link under “Your Personal Records”
3. Click on the BUILD YOUR OWN Starting at $9.00 link (prices may change without notice)
STEP 1: Under BUILD YOUR OWN INSTANT SEARCHES:
Click the QTY drop box and select 1 National Criminal File ……Instant Results, $25.00
STEP 2: Under BUILD YOUR OWN OTHER SEARCHES & VERIFICATIONS
Select: County Criminal Search …..………Results in 3 Business Days $16.00 per County
Click QTY drop box, select the number that includes every County you have lived in the last 7 years.
Click CONTINUE after ordering both National and County searches.
4. ENTER YOUR INFORMATION To continue, provide all personal information required.
Make sure the way you enter your name matches your social security card exactly.
If you try to enter your ID information 3 times and the system cannot confirm your identity, you must logon
to www.experian .com and order a copy of your credit report to ensure you are using your name exactly as it
appears in your Experian credit report. Wait 72 hours from your last attempt and reenter your name and
identification data exactly as it appears on Experian report.
Have you lived at your current address 6 months or less? IF YES, you are REQUIRED to enter both
your current address and your previous address in order to run the report.
Click the box to AUTHORIZE CHOICETRUST to initiate this report and then click SUBMIT.
(If you are unable to complete Step 4, contact Dorothy Fisk in WH124 or call Admissions (917-4811) for further
instructions. THIS SHOULD BE A LAST RESORT. THE MANUAL PROCESS MAY COST MORE THAN ONLINE.)
5. SIGN IN
Click on I AM A NEW MEMBER (if it is not already selected).
6. OPEN AN ACCOUNT
Enter your CREDIT CARD INFORMATION
1) Create & Enter your USER ID 2) Create & Enter your PASSWORD 3) Verify your password
Write your USER ID here __________________________________________________
Write your PASSWORD here _______________________________________________
(OPTIONAL: Enter ADDITIONAL INFORMATION)
Read and CLICK USER AGREEMENT box. Click SUBMIT
7. PLEASE CONFIRM IDENTITY INFORMATION
Confirm all identity information is correct. Click SUBMIT
8. IDENTITY QUIZ: You have 5 minutes to complete the quiz, this is timed by the computer.
WARNING: DO NOT click “BACK” or “REFRESH” buttons while taking this quiz as you will be unable
to complete the quiz.
Complete the quiz Click SUBMIT
9. REVIEW YOUR ORDER
Confirm the quantity and description of the order and charges to ensure they are accurate.
Review YOUR INFORMATION for accuracy. Click SUBMIT
10. PLEASE NOTE: EXTREMELY IMPORTANT. ……….DO NOT MISS THIS STEP!
YOU MUST SHARE YOUR RESULTS AFTER THE REPORT IS RETURNED TO YOU.
Please wait 3-5 business days, logon to your choicetrust.com account. Select I am an existing
member –logon to your account with your User ID and Password and click on My Products to view
your report information.
Check to see if ALL your reports are returned. If they are, review them and then follow these
procedures.
Click on SHARE THIS REPORT Click on SHARE Click on GET STARTED
Double check and be sure all of your reports have been returned.
There should be one National search and however many county searches you ordered (based on
how many counties you lived in within the last seven years).
BE SURE TO SELECT ALL OF THE REPORTS (both National and county checks) listed that you
will be sharing with LBCC.
The email address to send to at LBCC to share your report is backgroundcheck@linnbenton.edu
ENTER the email address in the TO box: backgroundcheck@linnbenton.edu Enter Employer Name.
This will authorize the company to notify LBCC when they can view your results.
ENTER a message if you choose to do so.
CLICK I AUTHORIZE CHOICEPOINT to send these results to the email address I provided.
CLICK SHARE REPORT.
11. NOW YOUR REPORT IS COMPLETE.
LINN-BENTON COMMUNITY COLLEGE
DATA AND IDENTIFY THEFT PREVENTION
Linn-Benton Community College has a commitment to privacy. The college wants to
assure you that we take the responsibility of handling your personal data very seriously.
The college takes every precaution to protect your confidential and personal data. The
college cannot guarantee the confidentiality or privacy of any other companies and takes
no responsibility for any other company and/or their handling of your personal data.
Please find attached a copy of Linn-Benton Community College’s privacy policy. A copy
of CHOICEPOINT’s privacy policy is available on their website at:
http://www.choicetrust.com
The college recommends that you watch your accounts carefully and regularly check
your credit reports for fraud. A recent amendment to the federal Fair Credit Reporting
Act requires each of the nationwide consumer reporting companies to provide you with a
free copy of your credit report, at your request, every 12 months.
For more info on your free credit report visit http://www.annualcreditreport.com
Also, the Federal Trade Commission under Facts for Consumers provides
information on accessing your free credit report. The website address is:
http://www.ftc.gov/bcp/conline/pubs/credit/freereports
AS A FRAUD ALERT: the college is providing information on “phishing” a new scam
designed to trick you into revealing your personal data.
Hot in the news today is that you can request a free credit report thanks to a new
Federal law. BE AWARE that authorities are warning people to NOT respond to
unsolicited offers to do this for you. These offers are bogus and are called phishing.
"PHISHING" is the latest scam to hit the Internet and LBCC. Phishing uses websites
that have been "SPOOFED" (websites that have been altered to look like a legitimate
site) in order to trick users into giving out sensitive information such as credit card
numbers, Personal Identification Numbers (PIN) and social security numbers.
A common method of Phishing is to send an e-mail to a person and ask them to fill out a
questionaire or go to a web site and fill in information. The e-mail usually states the
company is updating their records or has lost the information.
NEVER EVER give out this information. Any reputable bank, credit union or investment
firm will not use this method of asking for personal information - nor will they call you on
the phone. If you are concerned, you should call your bank yourself, using the phone
number on your bank statement. If you think you mistakenly responded to a phishing
email, contact your real bank or other organization
RM/PrivacyIDTheft
LINN-BENTON COMMUNITY COLLEGE
CRIMINAL BACKGROUND CHECK MANUAL IDENTIFICATION PROCESS
Having trouble getting past the identity check?
If you have tried three (3) times and the choicetrust.com web site cannot verify your
identity, you will be locked out of the system. You must now use the manual identity
authentication process.
Follow the steps below to manually confirm your identity and run a criminal background
check.
1. COLLECT and BRING the following documents to Dorothy Fisk in Willamette
Hall, WH124:
a. Your driver’s license or other government issued photo identification
b. A bank or utility statement with your name and current home address
(must match photo ID)
c. Your social security card
2. COMPLETE AN ORDER FORM which permits the college to electronically request
a criminal background check from CHOICEPOINT on your behalf.
3. PAY THE ESTIMATED COST AT THE BUSINESS OFFICE windows (located in
the College Center Building). Please tell the Business Office cashier that you need
to pay for a criminal background check with DETAIL CODE: MCBK. You must pay
the entire amount before your background check may begin to be processed.
4. You may check back in 5 business days to ensure your report has been completed
and the results of the check have been returned.
You may bring photo ID to Dorothy Fisk in Williamette Hall, WH124 to receive a printout of your CBC
MANUAL CRIMINAL BACKGROUND CHECK ORDER FORM
LINN-BENTON COMMUNITY COLLEGE – STUDENT
6500 SW PACIFIC BLVD SW, ALBANY OR 97321
Phone: 541-917-4936 Fax: 541-917-4831
APPLICANT INFORMATION
Last Name: First Name M:
SSN: DOB:
Address:
City: State Zip Code
Please perform the following services: County/State
$_16.00 (Per County) Felony & Misdemeanor Criminal Record Search (PRI-FM)
$ _9.75_ (Per County) Federal Felony & Misdemeanor Criminal Record
Search (PRI-FFM)
$ _10.00 National Criminal File
$______ Estimated Cost
I agree & acknowledge, by my signature below, that I will pay all charges for this background check.
I hereby give permission to Linn-Benton Community College to charge my LBCC student account
for any difference between the initial estimated amount that I have paid and any additional actual
cost of this background check.
Linn-Benton Community College will charge your student account if the estimated amount you
initially paid for the criminal background check costs more than what you paid. If it costs less than
what you paid, it will be credited to your student account. (If you paid your student account by
credit card and the cost is less than what you paid, the credit amount will be returned to your credit
card and will show up on your credit card billing statement.)
Applicant’s Signature: Date:
----------------------------------------------------------------------------
THIS SECTION FOR OFFICE USE ONLY
I certify that I personally reviewed and verified the identification documents of this individual:
Printed name of person verifying identification:
Phone number: Fax number:
Email address:
Title:
Name of College: Date:
You may bring photo ID to Dorothy Fisk in Williamette Hall, WH124 to receive a printout of your CBC
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