ATTESTATIONOF COMPLIANCEwithBackgroundScreening Requirements
Authority:Thisformmaybeusedbyallemployeestocomplywith:
•theattestationrequirementsof section435.05(2),FloridaStatutes,whichstatethat everyemployee requiredtoundergoLevel2 background screeningmustattest, subjecttopenaltyofperjury,to meetingthe requirementsfor qualifyingforemploymentpursuanttothischapterandagreeingtoinformtheemployer immediatelyif arrestedforanyofthedisqualifying offenseswhileemployedbytheemployer; AND
•theproofof screeningwithintheprevious5yearsinsection 408.809(2),FloridaStatuteswhichrequires proofofcompliancewith level2 screeningstandardsthat have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse.
Thisformmustbemaintainedintheemployee’spersonnelfile.Ifthisformisusedasproofofscreeningforan administratororchieffinancialofficer tosatisfytherequirementsof an applicationfor ahealth careproviderlicense,pleaseattachacopyofthescreeningresultsand submit withthelicensureapplication.
Employee/ContractorName:
HealthCareProvider/EmployerName:
AddressofHealthCareProvider:
IherebyattesttomeetingtherequirementsforemploymentandthatIhavenotbeenarrestedfororbeen foundguiltyof,regardlessof adjudication,orenteredapleaof nolocontendere,orguiltyto anyoffense,
orhaveanarrestawaitingafinaldispositionprohibitedunderanyof thefollowingprovisionsof theFlorida
Statutesorunderanysimilarstatuteof anotherjurisdiction:
Criminal offensesfoundin section435.04,F.S.
(a) Section393.135, relatingtosexualmisconductwith certaindevelopmentally disabledclients andreportingof suchsexualmisconduct.
(b) Section394.4593,relatingtosexualmisconductwith certainmental healthpatients andreportingof suchsexual misconduct.
(c)Section415.111,relatingtoadultabuse,neglect,or exploitationofaged personsordisabled adults.
(d) Section 777.04, relating to attempts, solicitation, and
conspiracy to commit an offense listed in this subsection.
(e) Section782.04, relatingtomurder.
(f) Section782.07, relatingtomanslaughter, aggravated manslaughterofanelderly personor disabledadult,or aggravatedmanslaughter ofachild.
(g) Section 782.071, relating to vehicular homicide
(h) Section782.09, relatingtokillingofanunbornquick childbyinjury tothemother.
(i) Chapter 784,relatingtoassault,battery, and culpable negligence, if theoffensewasafelony.
(j) Section 784.011, relatingtoassault,if thevictimof the offensewasaminor.
(k)Section784.03,relatingtobattery,if thevictimof the
offensewasaminor.
(l) Section787.01, relatingtokidnapping.
(m) Section 787.02, relatingtofalseimprisonment.
(n) Section 787.025, relating to luring or enticing a child.
(o) Section787.04(2),relating totaking, enticing, or removingachildbeyond thestatelimits with criminalintent pending custody proceedings.
(p) Section787.04(3),relating tocarrying a childbeyond the statelineswithcriminalintent toavoidproducingachildata custody hearingor deliveringthechild tothedesignated person.
(q) Section790.115(1),relating toexhibiting firearms or weaponswithin1,000feet ofaschool.
(r) Section790.115(2)(b),relatingtopossessinganelectric weaponor device,destructivedevice, or other weaponon school property.
(s) Section 794.011,relatingtosexualbattery.
(t) Formers.794.041,relatingtoprohibitedacts of persons in familial or custodialauthority.
(u)Section794.05,relating tounlawfulsexualactivity with certainminors.
(v) Chapter796,relatingtoprostitution.
(w) Section 798.02,relatingtolewdandlasciviousbehavior. (x) Chapter 800,relatingtolewdness andindecent
exposure.
(y) Section 806.01,relatingtoarson.
(z) Section810.02,relatingtoburglary.
(aa) Section810.14,relatingtovoyeurism, if theoffenseis a felony.
(bb) Section810.145,relatingtovideovoyeurism, if the offense isafelony.
(cc) Chapter 812,relatingtotheft, robbery,andrelated crimes, if theoffenseis afelony.
(dd)Section817.563, relatingtofraudulentsaleof controlled substances, only iftheoffensewasafelony.
(ee) Section 825.102,relatingtoabuse,aggravatedabuse, or neglect of anelderly personordisabled adult.
(ff) Section 825.1025,relatingtolewd or lascivious offenses committed uponor inthepresenceofanelderly personor disabledadult.
(gg)Section825.103, relatingtoexploitationofanelderly personor disabledadult,if theoffense wasafelony.
(hh) Section 826.04, relatingtoincest.
(ii) Section 827.03, relatingtochildabuse,aggravated childabuse, or neglectofachild
(jj) Section 827.04,relating tocontributingtothe delinquency or dependency of achild.
(kk) Formers.827.05,relatingtonegligenttreatment of children.
(ll)Section827.071, relatingtosexualperformance by a child.
(mm) Section 843.01,relating toresistingarrest with violence. (nn)Section843.025, relatingtodeprivinga law
enforcement, correctional, orcorrectional probationofficer
meansofprotectionorcommunication.
(oo) Section 843.12, relatingtoaidinginanescape.
(pp) Section843.13, relatingtoaidingin theescape of
juvenileinmates incorrectionalinstitutions.
(qq) Chapter 847,relatingtoobsceneliterature.
(rr) Section 874.05(1),relating toencouragingor recruiting another tojoinacriminalgang.
(ss) Chapter 893,relating todrugabusepreventionand control, only if theoffensewasafelony or ifany other person involvedin theoffensewasaminor.
(tt)Section916.1075, relatingtosexualmisconductwith certainforensic clients andreportingof suchsexual misconduct.
(uu)Section944.35(3),relating to inflictingcruelorinhuman treatment onaninmateresulting ingreatbodily harm.
(vv) Section944.40,relating toescape.
(ww) Section 944.46,relatingtoharboring,concealing, or aidinganescapedprisoner.
(xx) Section 944.47,relatingtointroductionof contraband intoacorrectionalfacility.
(yy) Section 985.701, relatingtosexualmisconduct in juvenilejusticeprograms.
(zz) Section 985.711, relatingtocontrabandintroducedinto detentionfacilities.
(3) Thesecurity backgroundinvestigations under this sectionmustensure thatnoperson subject tothis section hasbeenfoundguiltyof, regardlessofadjudication,or entereda pleaofnolocontendereor guiltyto,any offense that constitutesdomestic violenceasdefinedins.741.28, whether such actwas committed in this stateor inanother jurisdiction.
Criminaloffenses found insection 408.809(4),F.S.
(a) Any authorizingstatutes, iftheoffensewasafelony.
(b) This chapter, if theoffensewasafelony.
(c)Section409.920,relatingtoMedicaidprovider fraud.
(d) Section409.9201, relatingtoMedicaid fraud.
(e) Section741.28, relatingtodomestic violence.
(f) Section 777.04, relating to attempts, solicitation, and
conspiracy to commit an offense listed in this subsection.
(g) Section817.034, relatingtofraudulentacts through
mail,wire,radio,electromagnetic, photoelectronic, or
photooptical systems.
(h) Section817.234,relatingtofalseandfraudulent
insuranceclaims.
(i) Section 817.481, relating to obtaining goods by using a
false or expired credit card or other credit device, if the
offense was a felony.
(j) Section 817.50, relating to fraudulently obtaining goods
or services from a health care provider.
(k) Section817.505,relatingtopatientbrokering.
(l) Section817.568,relatingtocriminaluseofpersonal
identification information.
(m) Section817.60,relatingto obtainingacredit card
through fraudulent means.
(n) Section817.61, relatingtofraudulentuseof credit cards, if theoffensewasa felony.
(o) Section831.01,relatingto forgery.
(p)Section831.02,relating touttering forgedinstruments.
(q) Section831.07, relatingtoforgingbankbills, checks,drafts,or promissory notes.
(r) Section831.09,relating touttering forgedbank bills, checks,drafts, or promissory notes.
(s) Section831.30,relating tofraudinobtainingmedicinal drugs.
(t) Section831.31,relating tothesale, manufacture, delivery,or possessionwiththeintenttosell,manufacture,
or deliver any counterfeit controlled substance, if the offense wasa felony
(u) Section 895.03, relating to racketeering and collection of
unlawful debts.
(v) Section 896.101, relating to the Florida Money
Laundering Act.
I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).
Date of Decision:
I have been granted an Exemption from Disqualification through the Florida Department of Health.
Date of Decision:
**A copy of the Exemption from Disqualification decision letter must be attached**
Ifyouarealsousing thisform toprovideevidenceofprior Level 2screening(fingerprinting) in thelast 5 yearsandhavenot beenunemployedfor morethan90days,pleaseprovide the followinginformation. Acopyofthepriorscreeningresultsmustbeattached.
PurposeofPriorScreening: ______
Screeningconductedby: DateofPrior Screening:
Agency for Healthcare Administration
Department of Health
Agency for Persons with Disabilities
Department of Elder Affairs
Department of Financial Services
Department of Children and Family Services
Attestation
Underpenaltyof perjury,I, ,herebyswearoraffirmthatImeetthe requirementsforqualifyingforemploymentin regardstothebackgroundscreeningstandardssetforthin Chapter435andsection408.809,F.S.Inaddition,Iagreetoimmediatelyinformmyemployerifarrested orconvictedof anyof thedisqualifyingoffenseswhileemployedbyanyhealthcareproviderlicensed pursuant to Chapter 408, Part II F.S.
Employee/ContractorSignatureTitleDate