CORI HIRING REVIEW FORM
Executive Office of Health and Human Services
Commonwealth of Massachusetts

This form documents the factors considered in making a hiring decision for a job candidate who has a record of conviction or pending offense of a crime that appears or is similar to a crime on Crimes Tables at 101 CMR 15.15. This form is to be used when the candidate has a criminal record showing a conviction or pending Table A crime, or a conviction of a Table B crime within the five- and ten-year time periods referenced under 101 CMR 15.08(1), or a pending Table B crime.   The form does not need to be completed when the person is not being hired because of an outstanding warrant.   Only Hiring Authorities in organizations that are subject to 101 CMR 15.00 must complete this form and only for those positions where a CORI is required.  The form must be completed to document both decisions to hire and not to hire on the basis of the CORI.  Where more space is needed, please attach additional sheets.  Please attach CORI and other documentation.  

Completed forms must be maintained in a secure location in accordance with 101 CMR 15.09(2).

If record shows any Table A crime (conviction or pending case), and the Hiring Authority wishes to hire that candidate, the Hiring Authority must submit this form to the EOHHS Secretary/designee or the applicable Agency Commissioner/designee as required under 101 CMR 15.09(3).  The Hiring Authority should not submit this form for further review if the record only shows Table B crimes. 

Completed forms must be sent to the appropriate contact person at the EOHHS department that is contracting or otherwise financing the program for which the individual in question will be working. For information on the correct department and contact person, please refer to www.mass.gov/hhs/cori. 

The Secretary/Commissioner/designee has 5 business days from receipt of form to disapprove hire or request additional information.  If prior to the expiration of the 5 business days, Secretary/Commissioner/designee advises Hiring Authority they do not intend to disprove hire or request additional information, Hiring Authority may proceed to hire.  

Name of Candidate: ___________________________________      Date: ______________

Position: ____________________________________________________________________

Prospective Employer: ________________________________________________________

Contact Person at Prospective Employer: ________________________________________

Crimes/Offenses
1.	How many convictions exist?   						See attached CORI report
2.	How many pending offenses exist?					See attached CORI report
3.	Does the record reflect convictions/pending offenses against (check all appropriate boxes)
a.	Persons		 Yes								
b.	Property		 Yes								
c.	Unclear		 Yes					
4.	For each Table A/B conviction, the record has been reviewed for the 
sentence imposed, including the length of any period of incarceration. 		 	 Yes  

Relationship of Criminal Acts to the Nature of Work to be Performed
5.	Does the position involve   [Criteria b, c, and d apply to EOHHS and EOHHS agencies.  POS vendors, subject to certification by CHSB, may chose to use these criteria.  They also may identify other criteria.]

a.	Potential for Unsupervised Contact with Clients? 		   		 Yes    No
b.	Access to issue or transfer funds?						 Yes    No
c.	Access to personal or medical information?	 Yes    No
d.	EOHHS agencies only - Access to DOR – CORI required data?		 Yes    No   
e.	POS providers only – Other?___________________________		 Yes    No
Note: If a POS provider has completed the CORI review for a reason other than potential for unsupervised client contact, it should be specified in (e) above.

Circumstances Surrounding Offenses
6.	The record has been reviewed to determine elapsed time since the conviction
/ pending offense(s)?  (see attached CORI report)				           		 Yes   
7.	What was the age of the candidate at conviction/pending offense(s)?           _________________
           Note:  You only need to provide an estimate of the person’s age.		
8.	Summarize the circumstances as described by the candidate.

9.	Does the candidate report that a dependence on drugs or alcohol was a 
contributing factor to their behavior at the time of the offense(s)?  			 Yes    No

Relevant Evidence of Rehabilitation or Lack Thereof 
10.	Has the candidate provided documentation of rehabilitation or the lack thereof?  
         If yes, explain.				 Yes    No 
                             		 Documentation attached
11.	Summarize any educational achievements, employment history, professional certifications, and/or contributions to the community that provide documentation of rehabilitation, include the source of supporting information (e.g., reported by candidate, certificate of completion provided and attached).								 Documentation attached

12.	Does the record reveal any violations of conditions of probation or parole?		 Yes    No
13.	List any other relevant information, including information submitted by the candidate or requested by the Hiring Authority.  Include any reference letters.	            	 Documentation attached

Following careful consideration of the foregoing, I recommend that the candidate:		 Be hired
												 Not be hired
___________________________________________________	      			____________
	              Signature, Hiring Authority							        Date

For Table A Convictions/Pending Offenses Only

Secretary/Commissioner/Designee advises Hiring Authority no intention to disapprove? 		 Yes

Secretary/Commissioner/Designee disapproves hire?						 Yes   

_______________________________________________					____________
Signature, Secretary/Commissioner/Designee						Date