Authority: This form may be used by all employees to comply with:
This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.
I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:
Criminal offenses found in section 435.04, F.S.
(a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.
(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(e) Section 782.04, relating to murder.
(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.
(g) Section 782.071, relating to vehicular homicide
(h) Section 782.09, relating to killing of an unborn quick child by injury to the mother.
(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
(j) Section 784.011, relating to assault, if the victim of the offense was a minor.
(k) Section 784.03, relating to battery, if the victim of the offense was a minor.
(l) Section 787.01, relating to kidnapping.
(m) Section 787.02, relating to false imprisonment.
(n) Section 787.025, relating to luring or enticing a child.
(o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
(p) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.
(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
(r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
(s) Section 794.011, relating to sexual battery.
(t) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.
(u) Section 794.05, relating to unlawful sexual activity with certain minors.
(v) Chapter 796, relating to prostitution.
(w) Section 798.02, relating to lewd and lascivious behavior.
(x) Chapter 800, relating to lewdness and indecent exposure.
(y) Section 806.01, relating to arson.
(z) Section 810.02, relating to burglary.
(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(bb) Section 810.145, relating to video voyeurism, if the offense is a felony.
(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
(dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
(ee) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
(ff) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
(gg) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.
(hh) Section 826.04, relating to incest.
(ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child
(jj) Section 827.04, relating to contributing to the delinquency or dependency of a child.
(kk) Former s. 827.05, relating to negligent treatment of children.
(ll) Section 827.071, relating to sexual performance by a child.
(mm) Section 843.01, relating to resisting arrest with violence.
(nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.
(oo) Section 843.12, relating to aiding in an escape.
(pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.
(qq) Chapter 847, relating to obscene literature.
(rr) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.
(ss) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.
(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.
(uu) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
(vv) Section 944.40, relating to escape.
(ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
(xx) Section 944.47, relating to introduction of contraband into a correctional facility.
(yy) Section 985.701, relating to sexual misconduct in juvenile justice programs.
(zz) Section 985.711, relating to contraband introduced into detention facilities.
(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.
Criminal offenses found in section 408.809(4), F.S.
(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(d) Section 409.9201, relating to Medicaid fraud.
(e) Section 741.28, relating to domestic violence.
(f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
(h) Section 817.234, relating to false and fraudulent insurance claims.
(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) Section 817.505, relating to patient brokering.
(l) Section 817.568, relating to criminal use of personal identification information.
(m) Section 817.60, relating to obtaining a credit card through fraudulent means.
(n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(o) Section 831.01, relating to forgery.
(p) Section 831.02, relating to uttering forged instruments.
(q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
(s) Section 831.30, relating to fraud in obtaining medicinal drugs.
(t) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony
(u) Section 895.03, relating to racketeering and collection of unlawful debts.
(v) Section 896.101, relating to the Florida Money Laundering Act.
If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.
Under penalty of perjury, I, hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.