AHCA Form 3100-0008: Attestation of Compliance with Background Screening Requirements

AHCA Form 3100-0008 PDF Details

This form must be maintained in the employee's personnel file.

Licensure: if used as proof of screening for an administrator or chief financial officer for a health care provider license, attach a copy of the screening results.

Exemption: if granted an Exemption from Disqualification through the Agency for Healthcare Administration or Florida Department of Health, attach the decision letter.

Arrest: an employee required to undergo Level 2 background screening must agree to inform the employer immediately if arrested for a disqualifying offense while employed.