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Instructions
State of Illinois
Health Care Worker Background Check Form
To fill out this form click in the space after First Name.
Use the Tab key to move into the next field. All fields are required
Please make sure all information is correct before printing the form.
Once all fields are completed you will print the form by clicking on the
PRINT button on the top of the form.
DO NOT SAVE THIS FORM, SAVING THIS FORM MAY
PROVIDE UNAUTHORIZED ACCESS TO YOUR
CONFIDENTIAL INFORMATION.
After you have made sure the form has printed correctly and all
information is complete and accurate, please click the CLEAR FORM
button. This will remove all your personal information from the form.
After clearing the form please close the browser.

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State of Illinois
Illinois Department of Public Health

Health Care Worker Background Check
Authorization and Disclosure for Criminal History Records Information (CHRI) Check
I hereby authorize the Illinois Department of Publ