Community HealthCorps Eligibility Verification Form Instructions (Form follows instructions.) All Community HealthCorps Members must be verified eligible to serve in the program. To verify eligibility, the Eligibility Verification Form (EVF) must be completed and attached to the Member Contract. Several parts of the EVF must be completed before the Member s first day of service, except for certain parts relating to delays associated with receipt of the results of State and FBI criminal history checks that have been initiated. Members cannot be enrolled without a completed EVF. The following instructions are intended for the Program Site s use. Part 1 of the EVF is for the Applicant/Prospective Member to complete: 1. Program Sites must determine a deadline and process for Applicants/Prospective Members to return the completed Part 1-A of the EVF, Part 1-B (the parental consent, if applicable), Part 1-C, and supporting documents (e.g., copies of acceptable identification) to you. The form must be completed and returned to the Program Site before the first day of service. Provide ample time to be able to complete Part 2. 2. Parts 1-A, 1-B, and 1-C are to be completed by the Applicant/Prospective Member and sent to the Program Site per its instructions. Those instructions should address: deadline, process for returning the EVF, and requests for any supporting documents. 3. Once the form is returned, check for proper completion of Parts 1-A, 1-B, and 1-C. If the requirement for parent/legal guardian consent is not applicable, discard Part 1-B of the EVF. Make sure you have received legible copies of documents for thorough examination. Acceptable forms of identification are listed on Part 2-A of the EVF. Part 2 of the EVF is primarily for the Program Site to complete: 1. Parts 2-A and 2-B are to be completed by the Program Site only. Except for reviewing the results of the State and FBI checks, these parts of the EVF must be completed on or before the Member s first day of service. 2. Part 2-A: This gathers information about the Member contract, start date, age, identity, citizenship or resident alien status, and the result of the Excluded Parties Verification List search. 3. Part 2-B: These are required certifications relating to the National Service Criminal History Check (NSCHC). Note: You must also complete the NSCHC sections of the OnCorps Member Profile. Please also note that terminology such as accompaniment and initiation have specific definitions which can be found in the Community HealthCorps guidance on the NSCHC process. RECORDKEEPING REQUIREMENT: The Eligibility Verification Form must be retained in the Member File as a part of the Member Contract for the mandatory 3 years after the close of a grant. If any litigation, claim, negotiation, audit or other action involving the records has been started before the expiration of the 3-year period, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular 3-year period, whichever is later. Please contact NACHC if you have questions about recordkeeping requirements. REVIEW BY NACHC: Pursuant to the requirements of the grant and the terms of the Sub-Recipient Agreement, NACHC may request to review copies of the Eligibility Verification Form and supporting documents for any enrolled Member. Program Sites are required to comply with this request and a review may result in findings requiring immediate corrective actions. Similarly, the failure to complete this form correctly or retain it in the Member File will result in compliance findings. Page 0 of 5 Eligibility Verification Form
PART 1-A NOTE: PART 1-B IS THE PARENT OR LEGAL GUARDIAN CONSENT FORM. Community HealthCorps Eligibility Verification Form PART 1-A (FOR APPLICANT/PROSPECTIVE MEMBER) INSTRUCTIONS: Part 1-A of this form is to be completed by the Applicant/Prospective Member. The form is required in order for the Program Site to determine if the Applicant is eligible to serve in Community HealthCorps and AmeriCorps. Please follow the Program Site s specific instructions on how to submit the completed form before the first day of service. If you are under 18 years of age, you must also submit a completed Parent/Legal Guardian Consent Form. First name Middle name Last name Street Address City State Zip Date of Birth: (month/day/year) Educational Requirement Permission to Conduct a National Service Criminal History Check (NSCHC) Your permission to conduct the NSCHC is required in order to be able to serve. If you do not check all boxes to the right to give us your permission, your application will not be considered. Publicity Release Check here only if you do NOT give us your permission. This is not required to be able to serve. Check box if you are UNDER 18 years of age. Check one of the following: U.S. citizen or national U.S. lawful permanent resident alien Community HealthCorps is an AmeriCorps-funded program. To be eligible to serve in an AmeriCorps program, all Members must have a high school diploma or its equivalency certificate (or agree to obtain a high school diploma or its equivalent before using an education award) and have not dropped out of elementary or secondary school in order to enroll as an AmeriCorps Member. I hereby certify that I (check all that are applicable): Possess a high school diploma or have earned an equivalency certificate. Do NOT possess a high school diploma or equivalency certificate. Agree to pursue a high school diploma or equivalency certificate during my term of service. Agree to obtain a high school diploma or its equivalent prior to using the education award and certify that I have not dropped out of elementary or secondary school in order to enroll as an AmeriCorps Member. ALL boxes in this section must be checked and the form signed/returned to give us your permission. I understand that selection into the program is contingent upon my consent to undergo a National Service Criminal History Check (NSCHC), the completion of a NSCHC, a review of the results, and a determination of suitability for service. The NSCHC is a requirement of the Serve America Act. I understand that the National Service Criminal History Check consists of the following: a name-based search of the National Sex Offender Public Registry website; state of service and state of residence criminal history checks; and an FBI fingerprint-based check. I authorize Community HealthCorps and/or the program site to conduct a National Service Criminal History Check, as well as authorize the program to share the results of that check within the program, as appropriate. I understand that I will have an opportunity to review and challenge the factual accuracy of a result before action is taken to remove or exclude me from this position with Community HealthCorps. To give permission, fill in the name of the program site: (name of program site), Community HealthCorps, the National Association of Community Health Centers (NACHC ) and the Corporation for National and Community Service (CNCS) are authorized to copyright, publish, use, sell, or assign any and all photographic pictures, videotapes and/or sound recordings taken or made of me, or in which I may be included in whole or part, without compensation to me. Permission is granted to allow these images and/or recordings to be put to legitimate use at the discretion of the program. I relinquish all rights, titles or interest to any furnished products, reproductions or facsimiles. READ & SIGN BELOW. If you are under 18, you must also submit a completed Parent or Legal Guardian Consent Form found on the next page. By signing below, I attest under penalty of perjury that all of my responses are true and accurate to the best of my knowledge; that I have provided and/or will provide authentic document(s) to Community HealthCorps ; and agree to be considered for a position in the program which entails a determination of my eligibility to serve which includes a National Service Criminal History Check. Signature of Member/Applicant (If under 18, submit the Parent or Legal Guardian Consent Form): Date (month/day/year): Page 1 of 5 Eligibility Verification Form (with Instructions at Page 0)
PART 1-B USE ONLY IF APPLICABLE. IF NOT APPLICABLE, DISCARD THIS PAGE. PART 1-B: TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF APPLICANT IS UNDER 18 YEARS OF AGE PROGRAM SITE OFFICIAL: DISCARD THIS PAGE IF NOT APPLICABLE. Member Name (First & Last) PARENT OR LEGAL GUARDIAN CONSENT FORM (if applicable) Community HealthCorps requires this form to be completed for all individuals who are under the age of 18 at time of application or enrollment into the program. The form must be completed and signed by a parent or legal guardian of the individual applying to the program. Checking a box amounts to an agreement with the associated statement. The original completed form must be returned by the applicant to the program by no later the individual s first day of service. By signing below, I attest to the following: I am the parent or legal guardian of (first and last name), an individual who is under the age of 18 years. I have been informed of the duties and responsibilities of a Community HealthCorps AmeriCorps Member, and I hereby give authorization for the individual in my custody to serve. By signing below: I authorize the program to conduct a National Service Criminal History Check (NSCHC), as well as authorize the program to share the results of that check within the program, as appropriate. I understand that the NSCHC consists of the following: a name based search of the National Sex Offender Public Registry website; state of service and state of residence criminal history checks; and an FBI fingerprint-based check. I authorize the following Publicity Release for the individual: Community HealthCorps, (name of program site), the National Association of Community Health Centers (NACHC ) and the Corporation for National and Community Service (CNCS) are authorized to copyright, publish, use, sell, or assign any and all photographic pictures, videotapes and/or sound recordings taken or made of him/her, or in which he/she may be included in whole or part, without compensation to the individual. Permission is granted to allow these images and/or recordings to be put to legitimate use at the discretion of the program. The individual relinquishes all rights, titles or interest to any furnished products, reproductions or facsimiles. Name of Person Giving Consent Address Relationship to Applicant/Member Signature Date Page 2 of 5 Eligibility Verification Form (with Instructions at Page 0)
PART 1-C NOTE: PART 1-C SHOULD BE FILLED OUT BY APPLICANT/PROSPECTIVE MEMBER PART 1-C: TO BE COMPLETED BY APPLICANT/PROSPECTIVE MEMBER Member Name (First & Last) EMERGENCY CONTACT INFORMATION Required. Complete all sections or write n/a. First name Middle name Last name Street Address City State Zip Phone Number Email Address Relationship to Member HEALTH CARE BENEFITS Members are eligible to be enrolled in health insurance if they are serving full time and do not already have coverage. Community HealthCorps is a full time (minimum 1,700 hours) program. A summary of the plan is offered in the Member Contract. The Program Site can provide you with more information about what they specifically offer to Members serving at their placement sites. Steps to complete this section correctly: (1) Check one of the below boxes to either accept or decline health insurance, AND (2) See the Program Coordinator to complete a health insurance waiver/enrollment form available at www.communityhealthcorps.org: Accepted the health insurance as offered. Declined the health insurance as offered and proof of health care coverage has been submitted to the Program Coordinator. Note to Program Site - Review this section carefully and complete the additional health insurance waiver/enrollment form. Requirements for AmeriCorps Member health care benefits can be found in the AmeriCorps Terms and Conditions (f/k/a AmeriCorps Provisions) applicable to the grant year. CHILD CARE BENEFITS Members may be eligible for a child care allowance to be paid directly to an approved provider if they are serving in a full time program. Community HealthCorps is a full time (minimum 1,700 hours) program. Requirements and eligibility criteria are in the AmeriCorps regulations, 45 CFR 2522.250. Information can also be found in the Member Contract. Steps to complete this section correctly: (1) Check one of the boxes below to state that you are either interested or not interested in applying for child care benefits Interested in applying for child care benefits and has notified the Program Coordinator. Not interested in applying for child care benefits. Page 3 of 5 Eligibility Verification Form (with Instructions at Page 0)
PART 2-A SEE NEXT PAGE FOR PART 2-B PART 2-A: TO BE COMPLETED BY PROGRAM SITE Member Name (First & Last) MEMBER CONTRACT Reminder: Pursuant to grant requirements, the Member s contracted term of service must be no less than 9 months and no greater than 12 months. First Day of Service: Must match the OnCorps Member Profile and Timesheet, egrants and the Member Contract. (month/day/year) Date Member Signed Contract: Must be on or before first day of service. (month/day/year) Record the GOVERNMENT ISSUED ID used to verify AGE and IDENTITY of the individual in the spaces below. AGE: State-issued driver's license State-issued or Federally-issued photo ID A United States Passport A report of birth abroad of a US Citizen (FS-240) A certificate of birth-foreign service (FS-545) Birth certificate showing that the individual was born in one of the 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, or the Northern Mariana Islands Check the applicable Individual is 18 years of age Individual is under 18 years of age. box: or older. (Must obtain signed Parent/Legal Guardian Consent form.) Document Issuing Authority: Document #: IDENTITY (PHOTO ID IS REQUIRED): State-issued driver's license State-issued or Federally-issued photo ID A United States Passport Document Issuing Authority: Document #: Identify the document used to verify the individual s CITIZENSHIP OR RESIDENT ALIEN STATUS. Any one (1) of these listed documents is adequate verification of eligible status. A social security card is not adequate documentation. For U.S. Citizens or U.S. Nationals: For Lawful Permanent Resident Aliens: Birth Certificate from one of the 50 states, the District of Permanent Resident Card (Form I 551) Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Alien Registration Card Receipt (Form I 551) Samoa, or the Northern Mariana Islands Valid U.S. Passport issued to the individual as a U.S. citizen U.S. Department of State Form FS 240, Report of Birth Abroad of a Citizen of the USA U.S. Department of State Form FS 545, Certification of Birth Abroad U.S. Department of State Form DS 1350, Certification of Report of Birth Certificate of U.S. Naturalization (Form N 550 or N 570) A passport indicating that U.S. Citizenship & Immigration Services (USCIS) has approved it as a temporary evidence of lawful admission for permanent residence An Arrival Departure Record (Form I 94) indicating that the USCIS has approved it as a temporary evidence of lawful admission for permanent residence Certificate of U.S. Citizenship (Form N 560 or N 561) CONTACT NACHC: If one of the above primary documents is not available, the program must obtain prior written approval from NACHC that other documentation is sufficient to demonstrate the individual s status as a U.S. citizen, U.S. national, or lawful permanent resident alien. Document Issuing Authority: Document #: I, THE UNDERSIGNED, HAVE REVIEWED THE ABOVE DOCUMENTS TO DETERMINE THE INDIVIDUAL S AGE, IDENTITY AND CITIZENSHIP OR RESIDENT ALIEN STATUS: Name of Reviewer: Signature: Date: Excluded Parties List Verification (mandatory) Go to www.sam.gov to conduct a named-based search. Was this search completed ON OR BEFORE the individual s first day of service? Yes No Is documentation of this search being retained in the Member File? Yes No After completing this search, this individual is deemed: Eligible to serve or Ineligible to serve Name of Individual Making Determination: Signature: Date: Page 4 of 5 Eligibility Verification Form (with Instructions at Page 0)
PART 2-B END OF FORM PART 2-B: TO BE COMPLETED BY PROGRAM SITE National Service Criminal History Checks Guidance is available at www.communityhealthcorps.org. Member Name (First & Last) *Reminders: Document accompaniment in timesheets; add dates of initiation, review and completion of each check to the OnCorps Member Profile. Enter Member s First Day of Service here: National Sex Offender Public Website Check Programs must complete a nationwide, name-based search using www.nsopw.gov. Consent State of Service Criminal History Check State of Residence Criminal History Check Check here if this State is the same as the State of Service. If checked, you do not need to complete the State of Residence section; move on to the next section. FBI Fingerprint-Based Check Check ONLY if true. FOR ALL STATEMENTS BELOW, I CERTIFY THAT: This check was completed BEFORE the Member s first day of service. Do not certify if the NSOPW check was completed on or after the first day of service. The results have been reviewed and the Member has cleared this search.* The printed results have been added to the Member s file or are kept. Prior written consent to conduct the State and FBI checks was obtained through the Eligibility Verification Form, or otherwise, and is in the Member s file. This check was initiated ON or BEFORE the Member s first day of service. Do not certify if the check was initiated after the first day of service. Results, even if through a vendor, were obtained from a CNCS-approved state repository. A current list of approved repositories can be found here. Results have been reviewed and the Member has cleared this search.* The documentation of initiation and results has been added to the Member s file OR. This check was initiated ON or BEFORE the Member s first day of service. Do not certify if the check was initiated after the first day of service. Results, even if through a vendor, were obtained from a CNCS-approved state repository. A current list of approved repositories can be found here. Results have been reviewed and the Member has cleared this search.* The documentation of initiation and results has been added to the Member s file OR. This check was initiated ON or BEFORE the Member s first day of service. Do not certify if the check was initiated after the first day of service. Results were obtained through a CNCS-approved state repository, through an FBI-approved channeler, or directly from the FBI. Results have been reviewed and the Member has cleared this search.* Documentation of initiation and results has been added to the Member s file OR. Opportunity for Review/Challenge Confidentiality Are the results of the checks being kept confidential? Yes No N/A If the search produced a record of offenses, was the Member given a reasonable opportunity to review/challenge the accuracy before action was taken on his/her application? Yes No N/A Payment of Costs Were or will the costs of the checks be paid for or reimbursed Yes No N/A by the Sub-Grantee, not the applicant/member? Accompaniment If accompaniment was required, was accompaniment documented? Yes No N/A Was accompaniment documented in OnCorps timesheets or in a memo to the Member s file with this pertinent information: dates, times and accompanier? Yes No N/A Complete the sections below only when all state, FBI and NSOPW checks have been completed for this individual. After completing the National Service Criminal History Check, this individual is deemed: Eligible to serve Ineligible to serve Signature: Printed Name: Date: Page 5 of 5 Eligibility Verification Form (with Instructions at Page 0)