Ahca Form 3100 0008 PDF Details

The AHCA 3100 0008 form serves as a critical document within the healthcare industry in Florida, designed to ensure the safety and integrity of its workforce through meticulous background screenings. Mandated under Florida Statutes sections 435.05(2) and 408.809(2), this attestation form is a declaration by employees, under penalty of perjury, that they meet the stringent requirements necessary for employment in the healthcare sector. The form outlines a comprehensive list of disqualifying offenses ranging from sexual misconduct and abuse to theft and drug abuse prevention violations. It emphasizes the necessity for individuals to have undergone a Level 2 background screening process either through the Care Provider Background Screening Clearinghouse or an equivalent agency assessment within the past five years. Additionally, the form articulates conditions under which an employee must inform their employer of any arrest related to these specified offenses while employed. This document not only acts as a testament of an individual's eligibility for employment but also plays a pivotal role in license application processes for healthcare providers, further showcasing its extensive impact across various facets of Florida's healthcare infrastructure.

QuestionAnswer
Form NameAhca Form 3100 0008
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesahca affidavit, ahca 3100 form, ahca background screening form, background attestation

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ATTESTATION OF COMPLIANCE

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.

Employee/Contractor Name:

Health Care Provider/ Employer Name:

Address of Health Care Provider:

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.

(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.

(g)Section 782.071, relating to vehicular homicide

(h)Section 782.09, relating to killing of an unborn 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.

AHCA Form # 3100-0008, January 2017

Rule 59A-35.090, F.A.C

Page 1 of 4

Form available at: http://ahca.myflorida.com/BackgroundScreening

(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.

AHCA Form # 3100-0008, January 2017

Rule 59A-35.090, F.A.C

Page 2 of 4

Form available at: http://ahca.myflorida.com/BackgroundScreening

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.

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 Families

AHCA Form # 3100-0008, January 2017

Rule 59A-35.090, F.A.C

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, January 2017

Rule 59A-35.090, F.A.C

Page 4 of 4

Form available at: http://ahca.myflorida.com/BackgroundScreening

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