(Applicant Name: First, Middle initial Last)
(Last 4 of Social Security Number)
I have applied for employment with One On One We Care and hereby authorize you to furnish the information requested below concerning my prior employment with your organization. In signing this authorization, I release your organization, its employees and/or its agents from any liability that may result now or later because of complying with this request.
Please return Employee Reference Form to OneOnOneWeCare@gmail.com
with Background Screening Requirements
Authority: This form shall be used by all employees to comply with:
the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND
the proof of screening within the previous 5 years in section 408.809(2) Florida Statutes, which requires proof of compliance with level 2 screening standards that 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.
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.
You must attest to meeting the requirements for employment and you may not have been arrested for and awaiting final disposition of, have been found guilty of, regardless of adjudication, or have entered a plea of nolo contendere (no contest) or guilty to, or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of state law or similar law 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.
(g) Section 782.071, relating to vehicular homicide
(h) Section 782.09, relating to killing of an unborn child by injury to the mother.
(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
(j) Section 784.011, relating to assault, if the victim of the offense was a minor.
(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(k) Section 784.03, relating to battery, if the victim of the offense was a minor.
(e) Section 782.04, relating to murder.
(I) Section 787.01, relating to kidnapping.
AHCA Form # 3100-0008, January 2017 Page 1 of 4
Rule 59A-35.090, F.A.C Form available at: http://ahca.myflorida.com/BackgroundScreening
(m) Section 787.02, relating to false imprisonment.
(hh) Section 826.04, relating to incest.
(n) Section 787.025, relating to luring or enticing a child.
(ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of 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.
(jj) Section 827.04, relating to contributing to the delinquency or dependency of a child.
(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
(kk) Former S. 827.05, relating to negligent treatment of children.
(II) Section 827.071, relating to sexual performance by a child.
(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
(mm) Section 843.01, relating to resisting arrest with violence.
(r) Section 790.115(2b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
(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.
(s) Section 794.011, relating to sexual battery.
(t) Former S. 794.041, relating to prohibited acts of persons in familial or custodial authority.
(pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.
(qq) Chapter 847, relating to obscene literature.
(u) Section 794.05, relating to unlawful sexual activity with certain minors.
(rr) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.
(v) Chapter 796, relating to prostitution.
(w) Section 798.02, relating to lewd and lascivious behavior.
(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.
(x) Chapter 800, relating to lewdness and indecent exposure.
(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.
(y) Section 806.01, relating to arson.
(z) Section 810.02, relating to burglary.
(uu) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(vv) Section 944.40, relating to escape.
(bb) Section 810.145, relating to video voyeurism, if the offense is a felony.
(ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
(xx) Section 944.47, relating to introduction of contraband into a correctional facility.
(dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
(yy) Section 985.701, relating to sexual misconduct in juvenile justice programs.
(ee) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
(zz) Section 985.711, relating to contraband introduced into detention facilities.
(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.
(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.
AHCA Form # 3100-0008, January 2017 Page 2 of 4
Criminal offenses found in section 408.809(4), F.S.
(m) Section 817.60, relating to obtaining a credit card through fraudulent means.
(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(o) Section 831.01, relating to forgery.
(d) Section 409.9201, relating to Medicaid fraud.
(p) Section 831.02, relating to uttering forged instruments.
(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.
(q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
(r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
(h) Section 817.234, relating to false and fraudulent insurance claims.
(s) Section 831.30, relating to fraud in obtaining medicinal drugs.
(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.
(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
(j) Section 817.50, relating to fraudulently obtaining goods or services from a health care provider.
(u) Section 895.03, relating to racketeering and collection of unlawful debts.
(k) Section 817.505, relating to patient brokering.
(v) Section 896.101, relating to the Florida Money Laundering Act.
AHCA Form # 3100-0008, January 2017 Page 3 of 4
Rule 59A-35.090, F.A.C Form available at: ittp://ahca.myflorida.com/BackgroundScreening
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 Il F.S.
AHCA Form # 3100-0008, January 2017 Page 4 of 4
US Department of Justice Federal Bureau of Investigation Criminal Justice Information Services Division
Authority: The FBI's acquisition, preservation, and exchange of information requested by this form is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes, hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L. 94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application. Social Security Account Number (SSAN Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records. Principal Purpose: Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint based checks. Your fingerprints and other information contained on (and along with) this form may be submitted to the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to the application. During the processing of this application, and for as long hereafter as may be relevant to the activity for which this application is being submitted, the FBI may disclose any potentially pertinent information to the requesting agency and/or to the agency conducting the investigation. The FBI may also retain the submitted information in the FBI's permanent collection of fingerprints and related information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature of your application, the requesting agency and/or the agency conducting the application investigation may also retain the fingerprints and other submitted information for other authorized purposes of such agency(ies Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b and all applicable routine uses as may be published at any time in the Federal Register, including the routine uses for the FBI Fingerprint Identification Records System (Justice/FBI- 009) and the FBI's Blanket Routine Uses (Justice/FBI-BRU Routine uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security or public safety matters to which the information may be relevant; to State and local governmental agencies and nongovernmental entities for application processing as authorized by Federal and State legislation, executive order, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized by law, treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing this application, they may have additional routine uses. Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice