ATTESTATION OF COMPLIANCE

with Background Screening

Requirements

Authority: This form may 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.

Employee/Contractor Name:

Health Care Provider/ Employer Name:

Address of Health Care Provider:

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. (f) Section 782.07, relating to manslaughter, aggravated
manslaughter of an elderly person or disabled adult, or
(a) Section 393.135, relating to sexual misconduct with aggravated manslaughter of a child.
certain developmentally disabled clients and reporting of
such sexual misconduct. (g) Section 782.071, relating to vehicular homicide

(b) Section 394.4593, relating to sexual misconduct with (h) Section 782.09, relating to killing of an unborn quick
certain mental health patients and reporting of such sexual child by injury to the mother.
misconduct.
(i) Chapter 784, relating to assault, battery, and culpable
(c) Section 415.111, relating to adult abuse, neglect, or negligence, if the offense was a felony.
exploitation of aged persons or disabled adults.
(j) Section 784.011, relating to assault, if the victim of the
(d) Section 777.04, relating to attempts, solicitation, and
offense was a minor.
conspiracy to commit an offense listed in this subsection.

(k) Section 784.03, relating to battery, if the victim of the

(e) Section 782.04, relating to murder.
offense was a minor.

(l) Section 787.01, relating to kidnapping.

AHCA Form # 3100-0008, May 2015 Rule 59A-35.090

Page 1 of 4 Form available at: http://ahca.myflorida.com/BackgroundScreening
 (hh) Section 826.04, relating to incest.
(m) Section 787.02, relating to false imprisonment.

(ii) Section 827.03, relating to child abuse,

(n) Section 787.025, relating to luring or enticing a child. aggravated child abuse, or neglect of a child

(o) Section 787.04(2), relating to taking, enticing, or (jj) Section 827.04, relating to contributing to the
removing a child beyond the state limits with criminal intent delinquency or dependency of a child.
pending custody proceedings.
(kk) Former s. 827.05, relating to negligent treatment
(p) Section 787.04(3), relating to carrying a child beyond the of children.
state lines with criminal intent to avoid producing a child at a
custody hearing or delivering the child to the designated (ll) Section 827.071, relating to sexual performance by a
person. child.

(q) Section 790.115(1), relating to exhibiting firearms or (mm) Section 843.01, relating to resisting arrest with violence.
weapons within 1,000 feet of a school.
(nn) Section 843.025, relating to depriving a law
(r) Section 790.115(2)(b), relating to possessing an electric enforcement, correctional, or correctional probation officer
weapon or device, destructive device, or other weapon on means of protection or communication.
school property.
(oo) Section 843.12, relating to aiding in an escape.
(s) Section 794.011, relating to sexual battery.
(pp) Section 843.13, relating to aiding in the escape of
(t) Former s. 794.041, relating to prohibited acts of persons juvenile inmates in correctional institutions.
in familial or custodial authority.
(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.
(ss) Chapter 893, relating to drug abuse prevention and
(w) Section 798.02, relating to lewd and lascivious behavior. 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

(tt) Section 916.1075, relating to sexual misconduct with
exposure.
certain forensic clients and reporting of such sexual
misconduct.
(y) Section 806.01, relating to arson.
(uu) Section 944.35(3), relating to inflicting cruel or
(z) Section 810.02, relating to burglary. 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 (ww) Section 944.46, relating to harboring, concealing, or
offense is a felony. aiding an escaped prisoner.

(cc) Chapter 812, relating to theft, robbery, and related (xx) Section 944.47, relating to introduction of contraband
crimes, if the offense is a felony. into a correctional facility.

(yy) Section 985.701, relating to sexual misconduct in

(dd) Section 817.563, relating to fraudulent sale of controlled
juvenile justice programs.
substances, only if the offense was a felony.

(zz) Section 985.711, relating to contraband introduced into

(ee) Section 825.102, relating to abuse, aggravated abuse,
detention facilities.
or neglect of an elderly person or disabled adult.

(3) The security background investigations under this

(ff) Section 825.1025, relating to lewd or lascivious
section must ensure that no person subject to this section
offenses committed upon or in the presence of an elderly
has been found guilty of, regardless of adjudication, or
person or disabled adult.
entered a plea of nolo contendere or guilty to, any offense
that constitutes domestic violence as defined in s. 741.28,
(gg) Section 825.103, relating to exploitation of an whether such act was committed in this state or in another
elderly person or disabled adult, if the offense was a jurisdiction.
felony.

AHCA Form # 3100-0008, May 2015 Rule 59A-35.090

Page 2 of 4 Form available at: http://ahca.myflorida.com/BackgroundScreening
Criminal offenses found in section 408.809(4), F.S.
(m) Section 817.60, relating to obtaining a credit card
(a) Any authorizing statutes, if the offense was a felony. through fraudulent means.

(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 (q) Section 831.07, relating to forging bank bills, checks,
conspiracy to commit an offense listed in this subsection. drafts, or promissory notes.

(g) Section 817.034, relating to fraudulent acts through

(r) Section 831.09, relating to uttering forged bank bills,
mail, wire, radio, electromagnetic, photoelectronic, or
checks, drafts, or promissory notes.
photooptical systems.

(h) Section 817.234, relating to false and fraudulent (s) Section 831.30, relating to fraud in obtaining medicinal
insurance claims. drugs.

(i) Section 817.481, relating to obtaining goods by using a

(t) Section 831.31, relating to the sale, manufacture,
false or expired credit card or other credit device, if the
delivery, or possession with the intent to sell, manufacture,
offense was a felony. 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
(l) Section 817.568, relating to criminal use of personal Laundering Act.
identification information.

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**

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.
Purpose of Prior Screening: ____________
Screening conducted by: Date of Prior Screening:

Agency for Healthcare Administration Department of Elder Affairs

Department of Health Department of Financial Services
Agency for Persons with Disabilities Department of Children and Family Services

AHCA Form # 3100-0008, May 2015 Rule 59A-35.090

Page 3 of 4 Form available at: http://ahca.myflorida.com/BackgroundScreening
Attestation

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.

Employee/Contractor Signature Title Date

AHCA Form # 3100-0008, May 2015 Rule 59A-35.090

Page 4 of 4 Form available at: http://ahca.myflorida.com/BackgroundScreening