TX HHS Form 3649. Assisted Living Facility Background Disclosure Statement for Applicants for Employment

The TX HHS Form 3649, Assisted Living Facility Background Disclosure Statement for Applicants for Employment, is a crucial document that helps facilities ensure the integrity of their hiring process. This form assists assisted living facilities in verifying the background information of job applicants, thereby promoting a safe and trustworthy environment for residents.

This disclosure statement consists of two main sections: Facility Information and Applicant Information. The facility must complete Section 1 and provide it to any applicant who applies for employment or incorporate the language provided into their facility application for employment. If an applicant indicates they have lived in another state within the past five years, the facility must conduct a name-based criminal history check in each state.

The form requires applicants to disclose whether they have been convicted of certain offenses described in Texas Health and Safety Code Section 250.006 or if they have lived in a state other than Texas within the past five years. The applicant must sign and date the completed disclosure statement, which is then returned to the facility manager.