Category Archives: Appendix

Screening Disclosure And Consent Form



Company Name: __________________________________________________________ (“Requesting Entity”)

In connection with your employment or application for employment (or contract for services) and any future employment (or contract for services) with [Company Name] you may have, investigative consumer reports and consumer reports, which may contain public record information, may be requested from XYZ Reporting Company. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drugs/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, criminal information, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information.  Such reports may contain public record information concerning your driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from XYZ Reporting Company such as previous driving record requests made by others from such state agencies or previous drug/alcohol tests and the results of such tests.  Such reports may also contain medical information relevant to process or effect the employment.

You have the right to receive, upon your written request within a reasonable period of time a complete and accurate disclosure of the nature and scope of the investigation requested.  You have the right to make a request to XYZ Reporting Company, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that XYZ Reporting Company has previously furnished within the two-year period preceding your request.  XYZ Reporting Company may be contacted by mail at: XYZ Reporting Company Address, or by phone at XYZ Reporting Company Phone Number.


I authorize and instruct XYZ Reporting Company to prepare a consumer report or investigative consumer report and to disclose all information obtained to the Requesting Entity and to any other entity who may request a copy of same from XYZ Reporting Company in the future (each a “XYZ Reporting Company User”), including relevant medical information, for the purpose of making a determination as to my eligibility for initial or continued employment (or contract for services), promotion, reassignment, retention or any other lawful purpose.  I further authorize XYZ Reporting Company to provide the Requesting Entity with any information previously or subsequently obtained in connection with my potential or continuing employment (or contract for services) with any other XYZ Reporting Company User.  I have been provided a copy of the summary of the rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA).  If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period.

I hereby fully release and discharge XYZ Reporting Company, the Requesting Entity, any XYZ Reporting Company User, and their respective affiliates, subsidiaries, directors, officers, employees, agents and attorneys thereof, and each of them, and any individual, organization, entity, agency, or other source providing information to XYZ Reporting Company from all claims and damages arising out of or relating to any investigation of my background for employment purposes.  This release is valid for all federal, state, county and local agencies, authorities, previous employers, military services and educational institutions.

New York Applicants Only:  I acknowledge receipt of a copy of Article 23-A of New York Correction Law.

By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that the information being released could affect my being hired, my employment, or my eligibility for promotion.

Today’s Date _______________ Signature    Social Security Number: _________-_______-________

Print your full name            Date of Birth: _________________________________________

Oklahoma Applicants Only:  I request a copy of any credit report requested on me.

Minnesota Applicants Only: I request a copy of any consumer report requested on me.

Notice to California Applicants

Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by XYZ Reporting Company during normal business hours.  You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at XYZ Reporting Company in person, by mail, or by telephone.  XYZ Reporting Company may be contacted by mail at XYZ Reporting Company Mailing Address, or by phone at XYZ Reporting Company Phone Number.  The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file.  If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.
I request to receive a free copy of any investigative consumer report ordered on me by checking this box.  (California applicants only)

Attached to this disclosure is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission.


The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.


1. You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.


2. You can find out what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

  • a person has taken adverse action against you because of information in your credit report;
  • you are the victim of identify theft and place a fraud alert in your file;
  • your file contains inaccurate information as a result of fraud;
  • you are on public assistance;
  • you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information.

3. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

4. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures.

5. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

6. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

7. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

8. You must give your consent for reports to be provided to employers, or reports that contain medical information. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer.  A consumer reporting agency must have your consent to give out medical information about you. Written consent generally is not required in the trucking industry. For more information, go to

9. You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at (888)-567-8688.

10. You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

11. Identity theft victims and active military personnel have additional rights. For more information, visit

States may enforce the FCRA, and many states have their own consumer reporting laws.  In some cases, you may have more rights under state law.  For more information, contact your state or local consumer protection agency or your state Attorney General.  Federal enforcers are:



Consumer reporting agencies, creditors and others not listed below Federal Trade Commission:  Consumer Response Center – FCRA Washington, DC 20580   1-877-382-4357
National banks, federal branches/agencies of foreign banks (word “National” or initial “N.A.” appear in or after bank’s name) Office of the Comptroller of the CurrencyCompliance Management, Mail Stop 6-6,Washington, DC 20219   800-613-6743
Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve BoardDivision of Consumer & Community AffairsWashington, DC 20551    202-452-3693
Savings associations and federally chartered savings banks (word “Federal” or initials “F.S.B.” appear in federal institution’s name) Office of Thrift SupervisionConsumer ComplaintsWashington, DC 20552    800-842-6929
Federal credit unions (words “Federal Credit Union” appear in institution’s name) National Credit Union Administration1775 Duke StreetAlexandria, VA 22314      703-519-4600
State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance CorporationConsumer Response Center, 2345 Grand Avenue, Suite 100Kansas City, Missouri 64108-2638     1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation, Office of Financial ManagementWashington, DC 20590     202-366-1306
Activities subject to the Packers and Stockyards Act, 1921 Department of AgricultureOffice of Deputy Administrator – GIPSAWashington, DC 20250     202-720-7051