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\par \tab \hich\af5\dbch\af31505\loch\f5 (1) If the Department \hich\af5\dbch\af31505\loch\f5 \par \tab \hich\af5\dbch\af31505\loch\f5 (5) If the Department determines an individual is not eligible for direct patient acces\hich\af5\dbch\af31505\loch\f5 1395i-4(c)(2). }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 . \par \tab \hich\af5\dbch\af31505\loch\f5 (3) If the Department denies or revokes a license, or denies direct patient access based upon arrest or criminal charges, the Department shall send a Notice of Agency Action to the covered provider and the covered \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) child abuse or neglect findings described in Section 78A-6-323; Crisis Line & Mobile Outreach Team also require a background screening for one-time clearance. \par \tab \hich\af5\dbch\af31505\loch\f5 (2) A covered contractor must ensure that the covered individual, being supplied by contract to a covered provider\hich\af5\dbch\af31505\loch\f5 : You may submit an Identity History Summary challenge to the FBI by writing to the following address: Attention: Criminal History Analysis Team1 1000 Custer Hollow Road, Headquarters You may submit the background check forms one of three ways: Bring them into the Utah Department of Agriculture and Food in person, submit by U.S. Mail, or by guidelines designated by the Department of Health, and all UNAR requirements. \par \tab \hich\af5\dbch\af31505\loch\f5 (7) "Covered individual": Sexual Violence Crisis Line The FBI has determined that under Public Law 105-251 private entities can receive FBI criminal data. \par \tab \hich\af5\dbch\af31505\loch\f5 (E) 76-10-1201 to 1229.5, Pornographic and Harmful Materials and Performances; e. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 6; This payment authorizes a subscription to the FBIs Rap Back System which continually monitors all fingerprint based criminal records in real time. How do I Renew my Concealed Firearm Permit? \par \tab \hich\af5\dbch\af31505\loch\f5 (a) an end stage renal disease facility; \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 7;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table Grid 8;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table List 1;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Table List 2; 1-800-371-7897 with conditions, during an appeal process, if the covered individual can demonstrate the work arrangement does not pose a threat to the safety and health of patients or residents. 534. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) an assisted living facility; or \lsdpriority62 \lsdlocked0 Light Grid Accent 5;\lsdpriority63 \lsdlocked0 Medium Shading 1 Accent 5;\lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 5;\lsdpriority65 \lsdlocked0 Medium List 1 Accent 5;\lsdpriority66 \lsdlocked0 Medium List 2 Accent 5; Wisconsin Background Check Forms & Publications Here's a variety of forms and publications to help you with the Background Check process. \lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 2;\lsdpriority70 \lsdlocked0 Dark List Accent 2;\lsdpriority71 \lsdlocked0 Colorful Shading Accent 2;\lsdpriority72 \lsdlocked0 Colorful List Accent 2;\lsdpriority73 \lsdlocked0 Colorful Grid Accent 2; \lsdpriority67 \lsdlocked0 Medium Grid 1 Accent 6;\lsdpriority68 \lsdlocked0 Medium Grid 2 Accent 6;\lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 6;\lsdpriority70 \lsdlocked0 Dark List Accent 6;\lsdpriority71 \lsdlocked0 Colorful Shading Accent 6; 1395tt; and {\f535\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\f536\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f537\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f869\fbidi \froman\fcharset238\fprq2 Cambria Math CE;} \par \tab \hich\af5\dbch\af31505\loch\f5 (14) "Patient" means an individual who receives health care services from one of the following covered provid\hich\af5\dbch\af31505\loch\f5 ers: These forms are only to be used by agencies who are authorized by statute, executive order, court rule, court order or local ordinance. I need to obtain a copy of my nationwide criminal history from the FBI. This rule was published in the July 1, 2018, issue (Vol. This form must be presented to the live scan agent AFTER DACS application is submitted in order for the prints to be linked to the applicant in DACS. Results from the in-state and out-of-state screening process will be mailed to providers in the form of a letter once completed. Headquarters A check or money order made payable to the "Utah Department of Health" may be . 1-888-222-2542 \par \tab \hich\af5\dbch\af31505\loch\f5 (e) Patient family members; and After 60 days if not linked to another licensed setting, the RapBack subscription will be closed and a new DACS application will be necessary to re-open for employment in a DHS licensed agency. The following factors may be }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 {\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);} I also agree that a copy of this form is valid like the signed original. I certify that all of the personal Employee Background Screening. Certified court docket or other certified records must be submitted in these cases, Having charges does not automatically disqualify you from providing foster/adoptive care. {\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\fbiminor\f31507\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f529\fbidi \froman\fcharset238\fprq2 Times New Roman CE;} Call: (801) 538-4242 \par \tab \hich\af5\dbch\af31505\loch\f5 (a) As required by Utah Code Subsection \hich\af5\dbch\af31505\loch\f5 \par \tab \hich\af5\dbch\af31505\loch\f5 Code R432-35 - Background Screening - Health Facilities; Utah Admin. each applicant and instructor signs a criminal background screening authorization form which must be available for review by the department; . 1-800-273-TALK(8255) \lsdpriority47 \lsdlocked0 List Table 2 Accent 3;\lsdpriority48 \lsdlocked0 List Table 3 Accent 3;\lsdpriority49 \lsdlocked0 List Table 4 Accent 3;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 3; Covered Provider - Direct Access Clearance System Process. The DPS must receive the authorization form with the "original" signature. \lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 2;\lsdpriority65 \lsdlocked0 Medium List 1 Accent 2;\lsdpriority66 \lsdlocked0 Medium List 2 Accent 2;\lsdpriority67 \lsdlocked0 Medium Grid 1 Accent 2;\lsdpriority68 \lsdlocked0 Medium Grid 2 Accent 2; One-time Adoption Background Screening Procedure: Background screenings are required for one-time adoptions. Multi-Agency State Office Building \par \tab \hich\af5\dbch\af31505\loch\f5 (a) by employmen\hich\af5\dbch\af31505\loch\f5 t; }}{\*\pnseclvl3 For example, if your disposition information is incorrect or missing, you may submit documentation obtained from the court having control over the arrest or the office prosecuting the offense. \par \tab \hich\af5\dbch\af31505\loch\f5 (x) maintenance staff; and \par \tab \hich\af5\dbch\af31505\loch\f5 The department may impose civil monetary penalties in accordance with Title 26, Chapter 23, Utah Health Code Enforcement Provisions and Penalties, if th\hich\af5\dbch\af31505\loch\f5 Fingerprints: Submit 2 correctly-rolled fingerprint cards per applicant to the Office, which we will submit to the Office of Public Safety to fulfill FBI requirements. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) is not a covered provider; and I have read the attached Privacy Statement and understand my rights according to this statement. Also located on the back of the FBI Applicant fingerprint card FD-258) Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. If you submit your forms via email, the Department will contact you to take payment over the phone. {\revtim\yr2020\mo4\dy22\hr14\min21}{\version2}{\edmins0}{\nofpages1}{\nofwords2655}{\nofchars15139}{\nofcharsws17759}{\vern125}}{\*\xmlnstbl {\xmlns1 http://schemas.microsoft.com/office/word/2003/wordml}} s, based on information obtained through the Direct Access Clearance System, the Department shall send a Notice of Agency Action to the covered provider and the individual explaining the action and the individual's right of appeal as defined in R432-30. \par \tab \hich\af5\dbch\af31505\loch\f5 (1) As required in Utah Code 26-21-204 the department may review relevant information obt\hich\af5\dbch\af31505\loch\f5 ained from the following sources: \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority39 \lsdlocked0 TOC Heading;\lsdpriority41 \lsdlocked0 Plain Table 1;\lsdpriority42 \lsdlocked0 Plain Table 2;\lsdpriority43 \lsdlocked0 Plain Table 3;\lsdpriority44 \lsdlocked0 Plain Table 4; \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 envelope address;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 envelope return;\lsdsemihidden1 \lsdlocked0 footnote reference;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 annotation reference; \par \par \tab \hich\af5\dbch\af31505\loch\f5 st enter required information into the Direct Access Clearance System to initiate and obtain a clearance for all individuals 12 years of age and older, who are not residents, and reside in the residential setting. In giving this authorization, I 1-800-371-7897 \par \tab \hich\af5\dbch\af31505\loch\f5 (d) the Department of Human Services' Division of Child and Family Se\hich\af5\dbch\af31505\loch\f5 rvices Licensing Information System described in Section 62A-4a-1006; ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff The Department may allow a . Headquarters Multi-Agency State Office Building 195 North 1950 West Salt Lake City, Ut 84116. \lsdpriority60 \lsdlocked0 Light Shading Accent 3;\lsdpriority61 \lsdlocked0 Light List Accent 3;\lsdpriority62 \lsdlocked0 Light Grid Accent 3;\lsdpriority63 \lsdlocked0 Medium Shading 1 Accent 3;\lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 3; The NICS conducts background checks on people who want to own a firearm or explosive, as required by law. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) a hospice; ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff The act requires the health facilities and Medicaid community based waiver providers complete a caregiver criminal history screening no later than 20 calendar days after the first day of employment. Sexual Violence Crisis Line \par \tab \hich\af5\dbch\af31505\loch\f5 (iv) a provider of medical, therapeutic, or social services, including a provider of laboratory and radiology\hich\af5\dbch\af31505\loch\f5 services; Utah Administrative Code; Topic - Health; Title R432 - Family Health and Preparedness, Licensing; . \lsdpriority63 \lsdlocked0 Medium Shading 1 Accent 6;\lsdpriority64 \lsdlocked0 Medium Shading 2 Accent 6;\lsdpriority65 \lsdlocked0 Medium List 1 Accent 6;\lsdpriority66 \lsdlocked0 Medium List 2 Accent 6; \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 \sqformat caption;}{\*\cs34 \additive _Equation Caption;}}{\*\listtable{\list\listtemplateid100{\listlevel\levelnfc1\levelnfcn1\leveljc0\leveljcn0 ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff \s30\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar\tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 If the applicant already has a RapBack subscription in DACS, the system will allow the screening agent to link to that application without paying new fees. Use Form I-9 to verify the identity and employment authorization of individuals hired for employment in the United States. Crisis Line & Mobile Outreach Team I understand that my personal information including name, DOB, SSN and fingerprints will be used for the purpose of . Covered Contractor - Direct Access Clearance System Process. Call 801-977-6800 to set up your appointment. 4222ce0cae934e960d122231f728497abe5a7ee1069aea1ca2b9d51b90103e59725d482b9f1a3970baed64bc5ce2b934dd6e8c284b67af90e1b35ce1fc568bdf This meeting requires the screening agent to verify the applicants identification and enter information contained on the identification into DACS. Hotlines Abuse/Neglect of Seniors and Adults with Disabilities 1-800-371-7897 Child Abuse/Neglect 1-855-323-DCFS(3237) Authority: The FBIs acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. \par A potential IPs background check must be completed, and a fingerprint appointment scheduled (when applicable), before working with eligible Medicaid clients. Our vision is for Utah to be a place where all people can enjoy the best health possible, where all can live, grow, and prosper in healthy and safe communities. \lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 2;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 3;\lsdsemihidden1 \lsdunhideused1 \lsdqformat1 \lsdpriority9 \lsdlocked0 heading 4; \par \tab \hich\af5\dbch\af31505\loch\f5 (e) child abuse or neglect findings described in Section 78A-6-323; \sbasedon0 \snext0 toc 4;}{\s25\ql \li720\ri720\sl240\slmult0\nowidctlpar\tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin720\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 {\*\colorschememapping 3c3f786d6c2076657273696f6e3d22312e302220656e636f64696e673d225554462d3822207374616e64616c6f6e653d22796573223f3e0d0a3c613a636c724d 1-888-421-1100 I authorize the Utah Department of Human Services Office of Licensing to investigate and continually monitor my past and present child and adult abuse, neglect and exploitation records, law enforcement, driver license, and any information which may be pertinent to my application according to Utah Code 62A-2-120, 121, 122, and Administrative . Crisis Line & Mobile Outreach Team \expnd0\expndtw-3\insrsid14438297 I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. Utah Domestic Violence {\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);} 2f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73848f4d0ac2301484f78277086f6fd3ba109126dd88d0add40384e4350d36 dc9ae318d601feffffff00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000ffffffffffffffffffffffff00000000000000000000000000000000000000000000000000000000 \par \tab \hich\af5\dbch\af31505\loch\f5 (a) Signs a criminal background screening authorization form which\hich\af5\dbch\af31505\loch\f5 must be available for review by the department; and Screening agent will require a disclosure form to be signed and uploaded into DACS in order for OL to conduct continual monitoring of the RapBack criminal database and all regional and state databases as statutorily required for that applicants employment or affiliation with a licensee. \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) passage of time; b17d4e9cd131584756689f604cd1255a60ec3dfbdcc160c05696cd4bd20f62c82ac7d815580f901dabea3dc5027a25d5dcece7c91322ac909de2881de073bad9 fa3528a6243ddf43d7c25673b85d6d0159327aec8477c360d26ee4ca4b144443115d6a8a254be5a1584bd00bc6270050408a24493db959e1259a43140f112567 432KB Noncriminal Justice Applicant's Privacy Rights Form 1081 Form Instructions 177KB Health Care Mississippi Background Check 192KB Regular Mississippi Background Check 171KB Applicants Living in Another State 169KB The Live Scan Fingerprint Authorization Form can then be taken to any Utah Division in the Department of Justice (DOJ) collects the information requested on this form as authorized by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522, Licensing. 1-800-897-LINK(5465), Abuse/Neglect of Seniors and Adults with Disabilities. These forms are only to be used by agencies who are authorized by statute, executive order, court rule, court order or local ordinance. d0cf11e0a1b11ae1000000000000000000000000000000003e000300feff090006000000000000000000000001000000010000000000000000100000feffffff00000000feffffff0000000000000000ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff d09bd06aa3566b55134452df4b51026a1f2f97648ebd9952e9dfdb2a1f53784da5500373caa74a35b6243476715e5708b11143cabd0b447b3eccb3609733fc52 \par \tab \hich\af5\dbch\af31505\loch\f5 (1) Utah Code, Title 26, Chapter 21, Part 2 requires that a covered employer be allowed to enter required information into the Direct Access Clearance System to initiate and obtain a cl\hich\af5\dbch\af31505\loch\f5 This screening requires a separate application (see below). Email:
[email protected], HotlinesAbuse/Neglect of Seniors and Adults with Disabilities Email:
[email protected], HotlinesAbuse/Neglect of Seniors and Adults with Disabilities \red192\green192\blue192;\red0\green0\blue0;\red0\green0\blue0;}{\*\defchp \fs22\loch\af31506\hich\af31506\dbch\af31505 }{\*\defpap \ql \li0\ri0\sa160\sl259\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 } For eligibility questions or concerns: 1-866-435-7414 Salt Lake City, UT 84116. 1-888-421-1100 \par {\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);} \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-8. \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 footer;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index heading;\lsdqformat1 \lsdlocked0 caption;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 table of figures; If you believe a background check has been triggered for some other than the reasons listed above, contact HR Records at
[email protected] or 512-471-4772. Criminal Background Screening Authorization Form. 0000000000005b436f6e74656e745f54797065735d2e786d6c504b01022d0014000600080000002100a5d6a7e7c0000000360100000b00000000000000000000 \tqr\tldot\tx9360\wrapdefault\hyphpar0\faauto\rin720\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 3;}{ \hich\af5\dbch\af31505\loch\f5 ety and health of patients or residents. \lsdqformat1 \lsdpriority31 \lsdlocked0 Subtle Reference;\lsdqformat1 \lsdpriority32 \lsdlocked0 Intense Reference;\lsdqformat1 \lsdpriority33 \lsdlocked0 Book Title;\lsdsemihidden1 \lsdunhideused1 \lsdpriority37 \lsdlocked0 Bibliography; Us department of justice criminal background check. If the employee answers "Yes" to #2 or #3 of the form, court dockets or case reports are required to be submitted along with the application. \par \tab \hich\af5\dbch\af31505\loch\f5 (i) any felony or class A convi\hich\af5\dbch\af31505\loch\f5 ction under Utah Code. ;}{\levelnumbers\'01;}\rtlch\fcs1 \af0 \ltrch\fcs0 7aca147a3e08ad9246bbf33e1637f535c8ede6069a9a9982a6de65cf6f35430899395af5fc251c1ac363b282d811ea3717a211dcbccc25cf36fc4d32cb8a0b39 Online Background Check Authorization form for Applicants. To schedule an appointment, please click here. }{\field{\*\fldinst {\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 PRIVATE }{ ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff Health, Family Health and Preparedness, Licensing Rule R432-35 Background Screening -- Health Facilities Notice of Proposed Rule (Amendment) DAR File No. {\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;} \par \tab \hich\af5\dbch\af31505\loch\f5 (2) "Clearance" means approval by the department under Section 26-21-203 for an individual to have direct patient access. Utah Admin. \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 5;}{\s26\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar\tqr\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 MVR screening requires an additional consent form. \pndec\pnstart1\pnindent720\pnhang {\pntxta .