Criminal Record Review · EEOC Green Factors

Individualized Assessment Worksheet

For client use before adverse action · EEOC Enforcement Guidance (2012) · FCRA compliance documentation.

Instructions: Complete this worksheet before taking adverse action based on criminal record information. Retain the completed worksheet for at least five (5) years as documentation of your EEOC and FCRA compliance, and provide a copy to 4SafeDrivers upon request for dispute response.

Part 1 — Applicant and position information

Date of assessment

Applicant full legal name

Position applied for / held

Department / location

Background check order ID

Report date

Assessor name and title

Part 2 — Criminal record(s) under review

#	Offense / conviction	Date / year	Jurisdiction
1
2
3

Part 3 — Green Factors assessment

Factor 1 — Nature and gravity of the offense (harm caused, violence/weapons, other relevant characteristics)

Factor 2 — Time elapsed since offense / sentence completion

Years since offense

Years since sentence completion

FCRA 7-year rule applicable? ☐ Yes ☐ No ☐ Salary exception (>$75K) State look-back limit: __________

Is the record within the applicable look-back period? ☐ Yes — may be reportable ☐ No — not reportable

Factor 3 — Nature of the job (duties related/unrelated to the offense; trust/access; supervision; work environment; direct nexus)

Direct nexus between offense and job duties? ☐ Yes (explain above) ☐ No ☐ Uncertain

Factor 4 — Evidence of rehabilitation and other mitigating factors (time without further activity, employment, education, references, etc.)

Part 4 — Opportunity for response

☐ Applicant was given pre-adverse notice and a waiting period

☐ Applicant submitted additional information / rebuttal (attach)

☐ Applicant did not respond within the waiting period

Part 5 — Assessment conclusion

☐ PROCEED WITH HIRE / NO ADVERSE ACTION — the record does not bear a direct nexus to the position, or the factors weigh in favor of the applicant.

☐ PROCEED WITH ADVERSE ACTION — the record bears a direct and material nexus to the position based on the factors documented above.

If adverse action is selected, document the specific factors that support the decision

Assessor signature

Assessor printed name and title

Date of assessment

RETAIN THIS WORKSHEET FOR A MINIMUM OF 5 YEARS. Provide a copy to 4SafeDrivers upon request for dispute response.