Physical Therapist Assistant Program
Please Note: Background Checks are ONLY for those who have been accepted into the Professional Phase of the PTA program and ONLY to be initiated at the instruction of the ACCE.
Criminal Background Check Information |
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Dear PTA Program Student/Learner: Changes are taking place within healthcare facilities nationally. These changes directly affect all health programs at Mercer County Community College. The Joint Commission of Accreditation of Healthcare Organization (JCAHO), which accredits healthcare facilities across the country, enforced background screening September 2004 and has set requirements mandating that students in a healthcare field must now complete the same background check as hospital employees. A background investigation must be completed prior to the start of the clinical education component of the Professional Phase of the PTA program at Mercer County Community College. Students are responsible for the payment of their background investigation, and American DataBank must conduct the investigation. Once accepted into the Professional Phase of the PTA program (not before!) You can initiate your background clearance by going to the following link for the website www.mercercollegecx.com and follow the steps. The profile information you input will be sent directly to Mercer upon completion. The following search is required for students attending facilities for clinical education through Mercer County Community College:
If you have any questions, please contact me (Barbara Behrens) or the Dean for the Division of Science & Health Professions. Sincerely, Barbara J. Behrens PTA Program Coordinator 609-570-3385 The following form represents what you would need to complete if you have been accepted into the Professional Phase of the PTA program, once directed to do so, or if you decide to apply to become a part of one of the other Health Profession programs at Mercer. As part of the requirements for clinical participation through Mercer County Community College, I authorize an investigation of my personal information. The investigation might include, but is not limited to criminal history records (from state, federal and other agencies). I understand that these records may be used for the participation of clinical into the aformentioned school’s health professions or nursing program. I authorize without reservation the full release of these records and for American DataBank and/or its agents contacted by American DataBank to obtain information. In addition, I release and discharge American DataBank, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process. I also authorize the full release of the information described above, without any reservation, throughout any duration of my enrollment at Mercer County Community College. I also certify that all information provided is correct on the application to the best of my knowledge. Any false statements provided will be considered just cause for denial of acceptance. Upon Request, American DataBank will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to:American DataBank, 820 Sixteenth St. 8th Fl., Denver, CO 80202 or by contacting us at 1-800-200-0853.
Please remember to go online at www.mercercollegecx.com and input your information. < Please Print>
Applicant's Name: _______________________________________________________________ First M.I. Last
Signature: ______________________________________ Date: _____mm/_____dd/_____ yy
Date of Birth: _____mm/_____dd/________ yy (this is used for only criminal and driving records retrieval.) Social Security Number: _______________ - ____________ - _______________ Driver's License Number: _______________________________ State: _______ Current Address: ___________________________________________________ Phone Number: ________________ Street Address ___________________________________________________ City State Zip Length of Residency: _____ # of Years
Have you ever been convicted of a crime: Misdemeanor : Yes ________ No__________ or a Felony: Yes__________No___________
Please fax this form to: 1-303-573-1779 (Confidential)
American DataBank 820 Sixteenth St., 8th Fl., Denver, CO 80202 Tel: 800-200-0853 Fax: 1-303-573-1779 |
