Background Check Disclosure Form: Stand-Alone FCRA Sample
This sample background check disclosure form tells an applicant that you may order a background report.
The FCRA requires it as a stand-alone document. Therefore, review the sample and the rules below.
Sample only: This form is a starting point, not legal advice. Therefore, ask your legal counsel to review it before use.
What Is a Background Check Disclosure Form?
A background check disclosure form tells an applicant that the employer may order a background report.
Under the Fair Credit Reporting Act (FCRA), the employer must give this notice in writing first. Moreover, the law requires a document that consists solely of the disclosure (15 U.S.C. § 1681b).
Consequently, employers call it a stand-alone disclosure. However, the disclosure does not record consent. Instead, the applicant signs a separate authorization.
What a Stand-Alone Background Check Disclosure May Include
Courts read the stand-alone rule strictly. Therefore, a short and plain form is the safer choice.
What may go in
- A plain statement that you may obtain a consumer report for employment purposes.
- Also, a brief explanation of what a consumer report is.
- How you obtain the report, including who prepares it.
- The employment purposes, such as hiring or promotion.
- Finally, a mention that the report may be an investigative consumer report.
What to keep out
- Liability waivers or releases.
- State and city law notices.
- Explanations of other rights, such as how to inspect an agency’s files.
- Job application questions or other acknowledgments.
- Likewise, vague wording that a reasonable reader would not understand.
Where these rules come from
First, the FTC guide for employers says the notice must be in a stand-alone format.
Additionally, the Ninth Circuit rejected a disclosure with state law notices and unclear wording (K&L Gates on Gilberg).
Later, the same court allowed a concise explanation of the report (Troutman Pepper on Walker).
However, courts in other regions may differ, so confirm the wording with your counsel.
Sample Background Check Disclosure Form
Read the full sample below. In addition, the blank line shows where the employer writes its name.
Disclosure Regarding Background Investigation
Sample form
(“the Company”) may obtain information about you from a third party consumer reporting agency for employment purposes. These purposes include hiring, promotion, reassignment and retention.
Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. An investigative consumer report gathers some of this information through personal interviews.
These searches will be conducted by:
BCS Background Screening LLC, 1172 South Dixie Hwy #257, Coral Gables, FL 33146. https://usabackground.com
The Company may obtain these reports when you apply and, if you are hired, at any time during your employment, to the extent permitted by law.
– End of Document –
Sample form by BCS Background Screening LLC. Updated October 2026.
Where the Other Background Check Notices Go
The disclosure stays short because other documents carry the rest. Therefore, use this table to place each item.
| Item | Where it belongs | Form |
|---|---|---|
| Applicant’s consent | In a separate authorization that the applicant signs and dates. | Authorization form |
| State and city provisions | Also in the authorization, not in the disclosure. | Eight local provisions |
| Rights for investigative reports | Likewise in the authorization, with the Summary of Rights. | Authorization form |
| California details | In a separate notice for California applicants and employees. | California notice |
| Credit check notices | In separate notices for Vermont and New York City. | All forms |
| Adverse action | In two letters, sent only when a report leads to a rejection. | Sample letters |
How to Use a Background Check Disclosure Form
- 1
Add Your Company Name
First, write your legal company name on the blank line.
Otherwise, leave the wording alone.
- 2
Give It as Its Own Document
Next, hand it over or show it on its own screen.
Importantly, keep it out of the job application.
- 3
Then Collect the Authorization
Afterward, have the applicant sign the separate authorization.
That form also confirms receipt of the disclosure.
- 4
Order the Report and Keep Proof
Finally, order the background check.
Also keep a record of when you gave the disclosure.
Prefer an online process? Then, applicants can view and sign each document through our mobile background screening.
Background Check Disclosure Form: FAQs
What is a background check disclosure form?
It is the written notice that tells an applicant you may order a background report.
Moreover, the FCRA requires it before you order the report.
What does stand-alone mean for a background check disclosure?
It means the document consists solely of the disclosure.
Therefore, keep it apart from the job application and other hiring papers.
Can the disclosure include a liability waiver or state notices?
No. Courts have rejected disclosures that carried liability waivers or state law notices.
Instead, place state and city provisions in the authorization or in separate notices.
Can the disclosure and the authorization be one document?
Yes. The FTC says the authorization can appear in the same document as the notice.
However, that document may contain nothing else.
Consequently, this sample keeps the two forms apart.
Does the background check disclosure form need a signature?
No. The FCRA requires you to give the disclosure in writing.
Instead, the applicant signs the separate authorization.
In addition, that form confirms that the applicant received the disclosure.
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Disclaimer: This sample form offers general information, not legal advice. BCS Background Screening LLC does not assume responsibility for its compliant content. Laws change, so consult legal counsel before you use it.