Background Check Request Form

Home Care Employee Screening Template (Editable MS Word)

Hiring trustworthy caregivers is one of the most important responsibilities of a home care agency. A background check authorization form helps your agency document consent to conduct employment screening and maintain proper personnel records.

This Background Check Request Form Template is designed specifically for non-medical home care agencies that need a professional and organized way to collect the information required before initiating employee screening.

The form allows agencies to document identifying information, previous addresses, government identification details, and authorization for criminal background review.

This document can be customized with your company information and used as part of your employee hiring and compliance documentation system.

Why Home Care Agencies Use This Form

Most states require home care businesses to perform background checks on employees who provide care services to vulnerable populations. Maintaining written documentation of this process helps demonstrate responsible hiring practices and supports regulatory compliance during audits or inspections.

This template provides a structured format to:

• Collect employee identification details
• Document consent to perform a background check
• Maintain organized personnel records
• Track verification and screening results
• Maintain professional documentation for agency files

Template Features

This digital template is designed for simplicity and flexibility so agencies can adapt it to their own internal hiring procedures.

✔ Fully editable Microsoft Word document
✔ Add your company logo and business information
✔ Can be completed digitally or printed and filled manually
✔ Suitable for electronic submission or paper personnel files
✔ Clean, professional format designed for business use

Instructions for adding your logo are included.

How Agencies Typically Use This Form

Many home care agencies include this form as part of their employee onboarding packet or pre-employment screening process. The completed document can be stored in the caregiver’s personnel file along with other hiring documents such as applications, reference checks, and training records.

Because every state has slightly different employment screening rules, agencies can easily modify the template to align with their internal policies.

File Format

• Microsoft Word (.DOCX)
• Fully editable text fields
• Standard letter size (8.5" × 11")
• Printable and digital-use friendly

About Wise Caregiving®

Wise Caregiving® provides specialized templates and administrative resources designed for the non-medical home care industry.

Each document is created based on real operational experience working with caregivers, families, and care organizations. The goal is to provide practical tools that help agency owners organize their business, streamline documentation, and build strong operational systems.

Thousands of agencies use Wise Caregiving templates as part of their internal business documentation.

Usage & Intellectual Property Notice

Wise Caregiving® templates are created to assist entrepreneurs in organizing and operating their own home care businesses.

Your purchase grants a single-business use license. You may edit and customize the document for use within your own agency or internal operations.

These materials remain the intellectual property of Wise Caregiving® and are protected by copyright and trademark law. Redistribution, resale, sharing, reproduction, AI-generated rewriting for resale, or inclusion within other digital products, templates, courses, or downloads is strictly prohibited.