Authorization for Release of Criminal History Information

I, Nasiba Burkhanova (Staff Name), hereby acknowledge that, as a condition of

placement by Talent4health (Agency Name) (“Agency”) at NYC Health +
Hospitals, a criminal history background search will be conducted.
By signing this form, I consent to the submission of my digital fingerprints to the
Federal Bureau of Investigation (FBI) for the purpose of conducting a national
criminal history records check. I also consent to the conduct of a criminal history
record search with the New York State Court Administration.
I further consent to and authorize the disclosure of all documents and information
Agency receives in response to the digital fingerprints and criminal history record
search for the purpose of the evaluation of my suitability for assignment with the
NYC Health + Hospitals and therefore, authorize the disclosure of all such
documents and information to NYC Health and Hospitals.
I expressly waive any privilege of confidentiality with respect to the release of any
such information to the Agency and NYC Health + Hospitals.
I understand and expect the Agency and NYC Health + Hospitals will use any
criminal history record information it receives only for authorized purposes and
will not retain or disseminate it in violation of local, state and/or federal statute,
regulation, rule, procedure or standard.
In the event an adverse decision is made by NYC Health + Hospitals based on my
criminal record, I will be informed of all information pertinent to that decision,
including the contents of the record and the effect the record had upon the decision,
consistent with all terms and provisions of the New York City Fair Chance Act.
I understand that should I be selected for placement at NYC Health + Hospitals,
and as a condition of continued placement at NYC Health + Hospitals, I agree to
report to Agency immediately upon being arrested, convicted, or pleading guilty to
one or more criminal offenses.
A photocopy of this authorization shall be considered effective and valid as the
original, which shall remain on file for this and any future reports or updates that
may be requested.
Applicant Certification:
I have read, understand and accept the contents of and conditions of use for
information provided on this Authorization for Release of Criminal History
Information Form. I hereby for myself, my heirs, executors, and administrators
release and forever discharge Agency and NYC Health + Hospitals and its officers
and agents from any and all claims, actions, or causes of action, which may arise as
a consequence of the release of the criminal history information to the Agency
and/or NYC Health + Hospitals.

_Nasiba 01/26/2021
Applicant Signature Date

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This section to be completed by Agency representative only
Fingerprint Compliance Confirmation:
The below signature with confirm that the FBI Fingerprint Compliance Process, as
required by NYC Health + Hospitals, has been completed accurately for (staff)
Nasiba Burkhanova and was conducted in accordance with Article -23A and NYC
Fair Chance Act.

Signature: __________________________________
Title: ______________________________________
Date: ______________________________________

Please attach a copy of the receipt for the fingerprint request. DO NOT include
any language or document which identifies any results from the fingerprinting
compliance process.