Health Informatics & Administration

Background Check

Instructions for Completing Forms

If you have been asked to have a criminal background check done in preparation for placement in fieldwork or a clinical internship, you must follow these instructions:

  1. Print this instruction sheet for reference. Then print these forms:
  2. Authorization and Release Form - Sign your name, date the form, print your name and include the name of your major or student classification (e.g., HCA).
  3. Background Information Disclosure Form – Check the box for “Other” on top of the form, and specify/write “HCA student.” Fill in the personal information in the next section near the top of the form, then answer each numbered question in Sections A, B, and C as well as the additional questions as applicable. Answer each question truthfully and completely, and provide details where prompted. Print your name and write the date at the bottom of the last page where prompted, and add your signature at the bottom.
  4. Bring all of your completed and signed forms to the HCA Internship Coordinator, Northwest Quadrant Building B, Room 6432. If you would prefer to mail or FAX the forms, send them to:
ATTN: HCA Internship Coordinator - CONFIDENTIAL
College of Health Sciences
P.O.Box 413
Milwaukee, WI 53201
FAX: (414) 229-3373

For those students that have lived outside of Wisconsin within the past three years, you MUST complete the Applicant Consent and Disclosure form as well in order for an out-of-state background check to be completed. Be sure to list all addresses covering the last 7 years and remember to sign the form.