The NYS DOH CHRC 102 form is the written consent that lets the New York State Department of Health run a fingerprint-based criminal background check on you before you start a direct-care or supervisory job at a nursing home, home care agency, or adult care facility. You complete your identifying information, sign the consent section, provide a separate sworn statement about any criminal history, and then attend a fingerprinting appointment your employer schedules and pays for. The form itself is short. The steps around it are where most applicants have questions.
Who Has to Sign It
Public Health Law Article 28-E requires this background check for prospective employees at nursing homes licensed under Article 28, home care services agencies licensed under Article 36, and adult homes, enriched housing programs, and residences for adults licensed under Social Services Law Article 7. The law reaches anyone providing direct care or supervision to patients or residents, including workers placed through temporary staffing agencies.
Two groups are outside the requirement: volunteers, and individuals licensed under Title Eight of the Education Law, which covers physicians, nurses, pharmacists, and similar professionals. If you fall into either category, you don’t sign a CHRC 102 for this purpose.
One structural point worth knowing: under Section 2899-a, the employer is the party that formally requests the check from the Department of Health. You are not applying to the state directly. Your job is to consent, disclose, and get fingerprinted.
Completing the Form
Your prospective employer supplies the form, which is titled “Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information.” It exists to identify you accurately enough that state and federal database searches return your records and not someone else’s.
Fill in your full legal name, any aliases you have used, your Social Security number, date of birth, and current residential address. Print legibly. Smudged or ambiguous entries can slow processing.
The signature block at the bottom is the consent itself. Signing and dating it authorizes the Department of Health to obtain your criminal history from the Division of Criminal Justice Services (DCJS) and, through DCJS, from the FBI. Sign before the employer submits anything. Once signed, the original stays in your personnel file at the employer, whether or not you end up hired.
The Sworn Criminal History Disclosure
Section 2899-a also requires you to submit a sworn written statement disclosing any prior criminal conviction in any jurisdiction and any prior finding of patient or resident abuse. This is separate from the fingerprint check. It is your own account, in your words, given before the database results come back. Employers must consider what you disclose when making hiring decisions, including any decision to let you start work on a temporary basis while the full check runs.
Be thorough. If you leave out a conviction that then surfaces on the fingerprint results, the omission itself becomes a problem, sometimes a bigger one than the underlying offense. For each conviction, include the nature of the offense, roughly when it happened, and the jurisdiction. If you have no convictions and no abuse findings, say so in the statement explicitly rather than leaving it blank.
What You Don’t Have to Disclose
Executive Law Section 296 bars employers and agencies from asking about or acting on arrests that ended in dismissal, adjournment in contemplation of dismissal, or a youthful offender adjudication, and on convictions sealed under Criminal Procedure Law Sections 160.55, 160.57, 160.58, or 160.59. If a case of yours has been sealed under one of those provisions, you generally do not have to disclose it, and the Department of Health cannot use it against you.
If you aren’t sure whether a specific case qualifies, request your own criminal history record from DCJS before completing the form so you know what appears on it.
What Happens After You Sign
The employer takes over the mechanics. A designated Authorized Person at the organization logs into the Department of Health’s Criminal History Record Check application inside the Health Commerce System, enters your information, and submits the electronic request. The system generates a fingerprinting appointment letter, which the Authorized Person retrieves from the HCS Document Viewer and passes to you along with a “Request for Scan Services” document.
Keep the Request for Scan Services document. You need it at the appointment. The Authorized Person also schedules the appointment and pays the fingerprint vendor through its website. The total cost is roughly $102, subject to periodic adjustment. You do not pay any part of it out of pocket. Passing the fee on to the employee is prohibited by statute.
The Fingerprinting Appointment
IdentoGO handles fingerprinting for the DOH CHRC at collection sites across New York. Bring a valid, unexpired government-issued photo ID, such as a New York driver’s license or non-driver ID card, and the Request for Scan Services document from your employer. Walk-ins are generally not available, so arrive at the scheduled time.
The vendor captures your prints electronically and transmits them to DCJS for the state search. DCJS forwards them to the FBI for the national check. If you have already been fingerprinted under this article and your prints are still on file with DCJS, a new state-level scan may not be necessary, though a fresh submission may still be required for the federal check.
If Your Prints Get Rejected
Scans can be rejected when the ridges come through too faint or distorted for the databases to read. People who type heavily, do manual labor, wash their hands often, or work around cleaning chemicals tend to have worn ridges. Older applicants often need more than one attempt. If your prints are rejected, you go back for a re-scan. Moisturizing your hands for a few days beforehand and avoiding harsh cleaners can help.
How Results Come Back
The fingerprint results go to the Department of Health, not directly to your employer. The Department reviews the record and issues a legal determination letter to the employer through the HCS Document Viewer. Clearance letters for applicants with no criminal history usually arrive within a few business days. Cases involving a record take longer because the Department has to analyze the offense before deciding on eligibility.
Some convictions carry near-automatic disqualification under Executive Law Section 845-b. In those cases, the Department denies eligibility unless it finds that approval “will not in any way jeopardize the health, safety or welfare of the beneficiaries of such services,” a high standard that generally requires substantial evidence of rehabilitation.
Other convictions are evaluated under Correction Law Article 23-A. Under Section 752, a conviction alone cannot disqualify you unless there is a direct relationship between the offense and the job duties, or hiring you would pose an unreasonable risk to patients or the public. Section 753 lists eight factors the Department weighs, including how long ago the offense occurred, how old you were, its seriousness, evidence of rehabilitation, and whether you hold a certificate of relief from disabilities or a certificate of good conduct, which creates a legal presumption of rehabilitation for the offenses it covers.
If the Department denies eligibility, you receive a written notice explaining why, and you can submit rehabilitation evidence during the response window. You cannot provide direct patient care, even under supervision, while that review is pending.
Starting Work Before the Results Arrive
New York permits employers to grant temporary approval so a prospective employee can begin working before the final determination lands. That approval is not unrestricted. A temporarily approved worker cannot provide direct patient care unless supervised by an employee who has already cleared the CHRC. The employer is responsible for the supervision arrangement. If the check ultimately returns a denial, temporary approval ends and you must stop providing care immediately.
Fixing Errors in Your Record
Criminal history databases contain mistakes. Records occasionally get attached to the wrong person, and dispositions like dismissals or acquittals sometimes fail to appear. You have the right to challenge inaccurate information. Contact DCJS at RecordReview@dcjs.ny.gov or 518-457-9847 between 8 a.m. and 4 p.m. on business days, and DCJS will give you instructions for reviewing your record and correcting errors. For problems in the federal (FBI) portion, DCJS can point you to the FBI’s own challenge process.
Section 2899-a directs the Commissioner to establish “convenient procedures for prospective employees to promptly verify the accuracy of their criminal history information,” so treat delay as something to push back on rather than tolerate. If your employer already received a denial tied to inaccurate records, tell them a challenge is in progress. The Department may hold the determination open while the correction moves through.
Your Rights During the Screening
When a third-party consumer reporting agency is involved in any part of the background screening, the federal Fair Credit Reporting Act applies. Under 15 U.S.C. ยง 1681b, the employer must give you a standalone written disclosure that a background check will be conducted and get your written consent before obtaining the report. If the employer decides not to hire you based in whole or in part on the results, federal law requires a two-step notice: a pre-adverse-action notice with a copy of the report and a summary of your rights, giving you time to dispute errors, followed by a final adverse-action notice after a reasonable waiting period.
At the state level, Executive Law Section 296 makes it an unlawful discriminatory practice for an employer to deny you a job based on a criminal conviction in violation of the Correction Law Article 23-A framework. If you believe an employer used your record improperly rather than applying the required analysis, that provision is where the claim lives.