AHCA Form 3100-0008 at a glance
What it is: AHCA Form 3100-0008 is the Attestation of Compliance with Background Screening Requirements.
Who signs: Sign on the Employee/Contractor Signature line and enter the Title and the Date.
This form may be used by all employees to comply with the attestation requirements of section 435.05(2), Florida Statutes, and the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes.
Every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer.
A filled-in AHCA Form 3100-0008 example: a new employee signs the attestation
How to fill out AHCA Form 3100-0008, box by box
Employee/Contractor Name, Health Care Provider/ Employer Name and Address of Health Care Provider
Enter the Employee/Contractor Name, the Health Care Provider/ Employer Name and the Address of Health Care Provider.
I hereby attest: criminal offenses in section 435.04 and section 408.809(4), F.S.
On the form, you attest to meeting the requirements for employment and that you have not been arrested for and 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 provisions of the Florida Statutes listed on the form or under any similar statute of another jurisdiction.
Criminal offenses found in section 435.04, F.S. and criminal offenses found in section 408.809(4), F.S. are listed on the form.
Exemption from Disqualification and Date of Decision
If you have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA), mark the box and enter the Date of Decision.
If you have been granted an Exemption from Disqualification through the Florida Department of Health, mark the box and enter the Date of Decision.
Common mistake: If you mark either exemption box, a copy of the Exemption from Disqualification decision letter must be attached.
Purpose of Prior Screening
If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years by the Department of Financial Services and have not been unemployed for more than 90 days, enter the Purpose of Prior Screening.
Common mistake: If you enter a Purpose of Prior Screening, a copy of the prior screening results must be attached.
Attestation: Employee/Contractor Signature, Title and Date
Under penalty of perjury, fill in the blank after I to swear or affirm that you 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, you agree to immediately inform your 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.
Sign on the Employee/Contractor Signature line and enter the Title and the Date.
Common questions about AHCA Form 3100-0008
Where do I file it?
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.
Sources
[1] AHCA Form 3100-0008 (July 2024), Attestation of Compliance with Background Screening Requirements, Agency for Healthcare Administration (the Official source link on this page).