# DEPARTMENT  OF  PUBLIC  SAFETY CURRENT CRIMINAL HISTORY RELEASE

I hereby voluntarily agree to permit the Delta College Department of Public Safety access to all information on file concerning my conviction record, if any, present or past, in accordance with Public Act 303 of 2002, Section 20173 (see attached), as a condition of Delta College's EMT program requir

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[Open original PDF →](https://www.delta.edu/programs/fire-science/_documents/criminal-release.pdf)

## Document text

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## DEPARTMENT  OF  PUBLIC  SAFETY CURRENT CRIMINAL HISTORY RELEASE

I hereby voluntarily agree to permit the Delta College Department of Public Safety access to  all  information  on  file  concerning  my  conviction  record,  if  any,  present  or  past,  in accordance with Public Act 303 of 2002, Section 20173 (see attached), as a condition of Delta College's EMT program requirements and/or scholarship opportunities.

As  a  condition of  continued  enrollment  in the  EMT  program,  I  agree  to  report, immediately,  in  writing,  upon  being  convicted  of  one  or  more  of  the  criminal  offenses covered by this law.

NAME:

Last

First

Middle Initial

RACE:

SEX:

DATE OF BIRTH:

Month

Day

Year

SOCIAL SECURITY #:

MICHIGAN DRIVER LICENSE #:

OTHER NAMES:

Last

First

Middle Initial

Last

First

Middle Initial

SIGNATURE:

(Applicant's Name)

DATE

UNIVERSITY CENTER, MICHIGAN 48710 PHONE (989) 686-9000 FAX (989) 686-8736

## EMPLOYEE BACKGROUND CHECKS

Public Act 303 of 2002, Section 20173 (1) requires that a health facility or agency that is a nursing home, county medical care facility, or home for the aged shall not employ, independently contract with, or grant clinical privileges to an individual who regularly provides direct services to patients or residents in health facilities or agency if the individual has been convicted of one or more of the following:

- (a)  A felony or an attempt or conspiracy to commit a felony within the 15 years immediately preceding the date of application for employment or clinical privileges or the date of the execution of the independent contract.
- (b)  A misdemeanor involving abuse, neglect, assault, battery, or criminal sexual conduct or involving fraud or theft against a vulnerable adult as that term is defined in the section 145m of the Michigan penal code, 1931 PA 328, MCL 750.14m, or a state or federal crime that is substantially similar to a misdemeanor described in this subdivision, within 10 years immediately preceding the date of application for employment or clinical privileges or the date of execution of the independent contract.

The Michigan Penal Code defines a vulnerable adult as one or more of the following: (i) An individual age 18 or over who, because of age, developmental disability, mental illness, or physical disability requires supervision or personal care or lacks the personal and social skills required to live independently.  (ii) An adult as defined in section 3(1)(b) of the adult foster care-licensing act, MCL 400.203.  (iii) An adult as defined in the section 11(b) of the social security welfare act, MCL 400.11.

## Public Act 303, Subsection 11

As a condition of continued employment all individuals involved with covered entities under this new law will be required to agree in writing to immediately report the fact that they have been arrested for or convicted of one (1) or more of the criminal offenses listed in subsection (1)(a) and (b).

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<small>Source: [https://www.delta.edu/programs/fire-science/_documents/criminal-release.pdf](https://www.delta.edu/programs/fire-science/_documents/criminal-release.pdf)</small>