Directions to complete CORI form

Full instructions on completing Criminal Offender Record Information (CORI) form for the Massachusetts clinical laboratory license applicants.

The Department of Public Health (Department) is required to conduct suitability reviews for all applicants applying for licensure as new health care providers.   The review includes a criminal background check of the applicant.  The Clinical Laboratory Program is registered under the provisions of M.G.L. c.6, § 172 to receive CORI from the Department of Criminal Information Services (DCJIS) for the purpose of screening current and otherwise qualified prospective license applicants, or current licensees.

The enclosed Criminal Offender Record Information (CORI) form must be completed and returned with the license application for all individuals (use full names) identified below so that determinations of suitability and responsibility can be made in a timely manner.

  • All individuals who hold a 5% or greater ownership or managerial interest in the facility;
  • If the applicant is a partnership, CORI forms must be completed for all general and limited partners with 5% or greater ownership interest in the partnership;
  • If the applicant is a for profit corporation, CORI forms must be completed for all officers, directors and holders of 5% or more of the corporation’s stock;
  • If the applicant is a not for profit organization, CORI forms must be completed for the officers of the board of directors, the executive committee, or other such governing body that has direct and ultimate control over the operation and compliance performance of the facility.
  • The program administrator.

In order to verify the information on your CORI request form, you may either (1) deliver your application to us in person, at which time we will verify the information on your CORI Acknowledgement Form, or (2) include a photocopy of a government-issued photographic identification with your CORI Acknowledgement Form that that has been notarized.

Acceptable forms or government-issued identification are: a state-issued driver’s license, state-issued identification card with photograph, a passport, a military identification card or Native American Tribal documents.

If you have any questions or concerns regarding the completion of these CORI forms please contact Clinical Laboratory Program staff at (617)753-8439.

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