Form 1: Security Clearance Form 1 (This form is to be used by all employees.)
Note: Physicians (MDs) complete this form
Form 2: * TDCJ-ID Non-Employee Background Questionaire (PERS-263):
(All employees except for Physicians (MDs) use this form. Additional forms may be
required depending on the questions answered. See details below.)
PDF Format WORD Format
* Additional Offender Information (PERS-282A):
PDF Format WORD Format
Requirements: All Employees including Contractors
Security Awareness Flowchart
There have been revisions to the
TDCJ Hospital Security Clearance Form 1
Background Questionnaire (PERS 263)—Form 2. Use only the versions of these forms found on the web page which
will always be the most current versions. Please destroy any
old Form 1 and old Form 2
security clearance forms.
Falsification Form is still required.
In some instances, TDCJ Human Resources requires additional information to accompany security clearance paperwork before processing can occur. Please check all Non-Employee Questionnaire forms to ensure that the following information is attached before submitting forms to the TDCJ Hospital Administration.
1. If question 14a, b, or c is answered YES, the applicant must complete an Additional Offender Information form (PERS 282A) for each listed name. The form can download from http://www.tdcj.state.tx.us or http://www.utmb.edu/tdcj.
2. If question 15, 16, or 17 is answered YES, the applicant must provide a disposition for charges. This information can usually be requested from the County Clerks Office, District Clerks Office or Court office.
We are committed to processing these forms immediately and as efficiently as possible. We need your assistance in reviewing the information prior to sending to our office to assure that all forms are complete and the necessary documents are attached.
The forms may be faxed to TDCJ Hospital Administration, Fax # 409-772-7623 (on campus ext. 27623) or campus mail Route 0449;
Or US Mail to:
UTMB – TDCJ Hospital Administration
301 University Blvd.
Galveston, TX 77555-0449
If you have any questions regarding these forms please call 409-772-5563 (on campus ext. 25563).
Please not that any security clearance forms submitted to our office without the required documentation will be returned to the requesting department unprocessed.