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VOLUNTEER IOWA NATIONAL SERVICE CRIMINAL HISTORY CHECK
DOCUMENTATION CHECKLIST FOR PROGRAMS
Effective May 1, 2021, ALL NSCHC components must be fully completed and adjudicated BEFORE the member/staff start date.
1.Name of individual in covered position:
4.☐ 1st ☐ 2nd ☐ 3rd ☐ 4th year member ☐ N/A
5.Gap in service or work < 180 days or less ☐ Yes ☐ No ☐ N/A
6.Verification of Identity and Legal Name (according to program policies)
☐Photocopy of government-issued photo ID included in member/staff file
☐Photocopy of other identification (allowed per program policy) included in member/staff file
☐Staff have verified that the first and last name(s) used for all NSCHC components EXACTLY matchesthe government issued/other ID attached. (Note that for NSOPW, no middle name or initial shouldbe entered)
7.Consent & Selection Notification
☐Documented consent from candidate before conducting the state and FBI components of theNational Service Criminal History Check and notifying the candidate that their selection is contingentupon the outcomes of the checks and that they will be provided a reasonable opportunity to reviewand challenge the factual accuracy of a result before action is taken to exclude them from theposition.
8.National Sex Offender Public Website (NSOPW) Check
NSOPW SOURCE (select one)
☐Truescreen – Date adjudicated in Truescreen:
☐NSOPW Website (www.nsopw.gov) – Date adjudicated:
☐Attached screenshots or printout of results from National Sex Offender Public Website(NSOPW) that clears the candidate in all registries. If the NSOPW search returned any resultswith the same name, documentation is included showing the candidate is not one of the listed.
9. State Records Check(s)
State of Service: IOWA
State of Residence (if other than Iowa at time of application):
☐ Not Required Due to National Fingerprint File (NFF) Waiver
For more information on pre-approved NSCHC Waivers (see Appendix A in NSCHC Manual)
Not Required Due to (select one): ☐ State of Residence is Iowa
☐ Truescreen Exemption
☐ National Fingerprint File (NFF) State
State of Service Source:
State of Residence Source:
Date Iowa Check Adjudicated:
Date State of Residence Check Adjudicated:
10. FBI Records Check
FBI Check Source:
Date FBI Check Adjudicated:
11. NSCHC Waiver (CHECK BELOW)
☐ This individual was cleared using a NSCHC Waiver that was approved for the program. Include the Waiver reference number. (For example, “Waiver-2016-001”.)
Waiver Reference Number:
12. Eligibility Determination
I have reviewed and considered the results of these checks and certify that this individual
☐ IS ELIGIBLE for work or service.
☐ Program must have additional documentation that the candidate is eligible to serve/work if a vendor returns a “do not recommend” result for the candidate.
☐ IS NOT ELIGIBLE/SUITABLE for work or service.
☐If the individual is ineligible to serve or unsuitable to serve according to organization-specific screening criteria and is denied an opportunity to serve, there is documentation that the individual was provided a reasonable opportunity to review and challenge the factual accuracy of a result before action was taken to exclude the individual from the position.
13. NSCHC Certification
I certify that I or my organization conducted, reviewed, adjudicated and determined eligibility/suitability for all necessary NSCHC components required for this individual before the member’s start date.
Signature of Selecting Official
Name of Selecting Official Title of Selecting Official
* Note: Corporation for National & Community Service (CNCS) is in the process of changing their public name, logo
and branding to AmeriCorps. For the purposes of space and simplicity, this document still uses the term “CNCS”.