TABB INCORPORATED - Designated Agent of the Department of Homeland Security

SAMPLE REPORT 8

TABB INC.

HUMAN RESOURCE SERVICES SERVICE IS OUR NUMBER ONE PRIORITY

PO BOX 10; 555 E. Main St., Chester, NJ 07930

TELEPHONE(908)879-2323/FAX NO. 879-8675

www.tabb.net

The information contained in this report is for the SOLE AND CONFIDENTIAL use of the subscriber.

DATABASE:

A database search under the applicant's social security number show the name ................. and the following cities and state(s): Ridgewood, Paramus, NJ and Brooklyn, NY

CRIMINAL RECORDS:

A statewide criminal record search was conducted in New Jersey. Please see the attached results found in a search conducted of New Jersey State records under the applicant's name, date of birth and social security number.

The applicant previously lived in New York. A statewide criminal record search was conducted in New York and there is no record of a felony or misdemeanor conviction under the applicant's name and date of birth.

A Federal criminal record search was conducted at the US District Court(s) in the states where the applicant has lived and there is no record of a felony or misdemeanor conviction under the applicant's name in these jurisdictions.

PROFESSIONAL LICENSE:

FACIS DATABASE SEARCH:

A search was conducted of the FACIS database and the applicant was not found in the search.

EDUCATION:

XYZ University Dates Given: 5/87

Dates Confirmed:5/15/87

The Registrar confirmed the applicant received a Bachelor of Science in Nursing on 5/15/87. The applicant's GPA was 2.61

EMPLOYMENT:

XYZ Hospital Dates Given: 2/05-12/07

Dates Confirmed: 6/1/05-11/15/07

The policy of this company requires that all requests for verification of employment must be submitted in writing. We complied and our written request was submitted. We received a written response from Mr. ......................., Human Resources Associate, confirming the applicant's employment as a Registered Nurse from 6/1/07 until 11/15/07. Mr. …………….. was informed of the Health Care Professional Responsibility and Reporting Enhancement Act and verified that the facility has not provided any notice to the licensing board or to the review panel with respect to this applicant's impairment, incompetence, professional misconduct, involvement in adverse patient care or safety, involvement in drug or alcohol abuse, involvement in intervention programs or any other issue as it relates to patient care or safety. Please see the attached form completed by this facility. The applicant's former supervisor, Ms. .................., Director of Nursing, confirmed the applicant worked full time in the pediatric unit on the night shift. The applicant's work performance was described as being "not up to standards". The applicant has poor clinical skills and was not motivated. In addition, the applicant was unreliable, often showing for work over a half-hour late and had more than the customary number of absences. Often the applicant appeared to be tired and lacked the necessary energy to perform her duties. The applicant was counseled on numerous occasions regarding these inadequacies. Often there was improvement for several weeks however, work performance reverted to the prior capabilities. The applicant worked well with other staff members on the floor and with patients however the applicant constantly had to be monitored to insure responsibilities were met. The applicant resigned from the position voluntarily and it is in the opinion of this reference that the applicant would not be eligible to return based on past work performance. The supervisor was informed of the Health Care Professional Responsibility and Reporting Enhancement Act and verified that the facility has not provided any notice to the licensing board or to the review panel with respect to this applicant's impairment, incompetence, professional misconduct, involvement in adverse patient care or safety, involvement in drug or alcohol abuse, involvement in intervention programs or any other issue as it relates to patient care or safety. Please see the attached form completed by this facility.

Medical Center Dates Given: 2/03-1/04

Dates Confirmed: 4/04-10/04

Ms. ..............., Human Resources Assistant, confirmed the applicant was employed as a full-time Registered Nurse from 4/04 until 10/04. Ms. ……….. was informed of the Health Care Professional Responsibility and Reporting Enhancement Act and verified that the facility has not provided any notice to the licensing board or to the review panel with respect to this applicant's impairment, incompetence, professional misconduct, involvement in adverse patient care or safety, involvement in drug or alcohol abuse, involvement in intervention programs or any other issue as it relates to patient care or safety. Please see the attached form completed by this facility. The individual indicated on the application as the applicant's former supervisor is not a current employee. We developed another former supervisor, Ms. .................., Nurse Manager, who was reluctant to discuss the applicant's work performance with our office. Ms................... had to be prompted to respond to our questions. The applicant's work performance was described as being adequate. Ms. ................... only worked with the applicant for a short time and stated that the applicant "did not impress me". Primarily there were issues with attendance and motivation. The supervisor answered our initial questions regarding the applicant, however this source was uncomfortable with the questioning and declined to comment further regarding work performance. Ms. …………. was informed of the Health Care Professional Responsibility and Reporting Enhancement Act and verified that the facility has not provided any notice to the licensing board or to the review panel with respect to this applicant's impairment, incompetence, professional misconduct, involvement in adverse patient care or safety, involvement in drug or alcohol abuse, involvement in intervention programs or any other issue as it relates to patient care or safety. Please see the attached form completed by this facility.

REPORT BY: ZA