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KENTUCKY STATE UNIVERSITY

Student ID# Last: First:

Phone #: Email:

Supervisor: Once student has been selected for the position, please complete, and return to the FWS coordinator to complete the HR process (background check and ADP access)

Department/ Location

FOAP

Student position title

Student's supervisor

Supervisor Email

Supervisor Phone number

Student's Schedule

Monday Tuesday Wednesday Thursday Friday

Student Signature: ________________ Date: __________

Supervisor Signature: ________________ Date: __________

By signing, I understand and agree with the condition set forth in this contract.

Student Signature: _____ Date:_____

Date:

As an employee with privileges at Kentucky State University, you may have access to what this agreement refers to as “confidential information.” The purpose of this agreement is to help you understand your duty regarding confidential information.

Confidential information includes employee, student, financial and other information relating to Kentucky State University and information proprietary to other companies or persons. You may learn of or have access to some or all of this confidential information through a computer system or through your employment activities.

Confidential Information is valuable and sensitive and is protected by law and by strict Kentucky State University policies. The intent of these laws and policies is to ensure that confidential information will remain confidential and that such information will be used only as necessary to accomplish the organization's mission. As an employee, you are required to conduct yourself in strict conformance to applicable laws and Kentucky State University policies governing confidential information. Your principal obligations in this area are explained below. You are required to read and be able to abide by these obligations. The violation of any of these obligations will subject you to disciplinary action up to and including discharge. You may also be subject to legal liability.

As an employee, you understand that you will have access to confidential information, which may include, but is not limited to, information relating to:

Accordingly, as a condition of and in consideration of your access to confidential information, you promise that you will use confidential information only as needed to perform your legitimate duties as an employee affiliated with Kentucky State University. This means, among other things:

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I understand and agree that any and all information I review, inspect or otherwise receive as an employee of Kentucky State University is being received by me solely in connection to my work at Kentucky State University. All such information is strictly confidential and proprietary and that no such information should be shared with any other person, unless I am specifically directed to do so by my immediate supervisor, by subpoena, or by a court of law. In addition, I understand that discussing such information is a breach of my agreement to maintain confidentiality. I also understand that such a breach may negatively affect the work, mission, property interests or reputation of Kentucky State University. Therefore, I will not discuss or disseminate any information or details concerning any Kentucky State University files, personnel, faculty, staff, or students outside the confines of my position with any person(s) including, but not limited to, persons involved in the Kentucky State University files, students, faculty, staff, or persons outside Kentucky State University, unless specifically directed to do so by my immediate supervisor, by subpoena, or by a court of law. I understand that maintaining confidentiality is a condition of my employment and that any breach of confidentiality may result in disciplinary action by my employer, up to and including termination.

Furthermore, I understand and agree that my duty of confidentiality continues beyond my employment at Kentucky State University and that failure to maintain confidentiality may subject me to additional action by my employer, including, but not limited to, a civil court action for injunctive relief and/or for damages. I also agree not to disparage or demean Kentucky State University or its reputation in any way related to information I have received in my position.

By signing below, I acknowledge that I have read this document, I understand that standards and expectations it sets for me, and I knowingly and voluntarily agree to abide by it while employed by Kentucky State University and afterward.

Printed Name

Date

Signature

Background Check Information Form

PART II: DISCLOSURE OF VIOLATIONS OR CONVICTIONS

I understand that state law requires a state and national criminal history and background check as a condition of employment. I further understand that a conviction reported below will not automatically disqualify me from employment.

Have you ever been convicted for any violation(s) of law, including moving traffic violations? ☐ Yes ☐ No If YES, please provide the following:

(For additional convictions use plain paper. Include all information listed above.) Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended? ☐ Yes ☐ No If yes, list here:

Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended? ☐ Yes ☐ No

The facts as stated on this form are true and correct. I understand that, if employed, false statements on this or any university form may cause my immediate dismissal.

\qquad\qquad Date: _____

Signature of Applicant: ___

Background Check Information 12 12 2018