UTMB TDCJ Hospital

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 and the TDCJ Non-Employee 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. The 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
Clearance Desk
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.