Fillable Criminal-conviction-screening-form-volunteer DONATION OF SICK LEAVE FORM

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Criminal-conviction-screening-form-volunteer DONATION OF SICK LEAVE FORM

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The Criminal-conviction-screening-form-volunteer DONATION OF SICK LEAVE FORM form is 3 pages long and contains:

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Country of origin: US
File type: PDF

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1
Name: ____ ___________________________________________________ SS#: ______________ DOB: ___________
Last First Middle Maiden
Address: ________________________________________________________Email Address: ___________________
Phone #: _________________Cell #: ______________Department Assignment______________________
Once approved as a volunteer, your fingerprints will be researched by local, state and federal law enforcement
agencies. Sealed or expunged records must be revealed to Nova Southeastern University (NSU) pursuant to
F.S. 943.058. Your volunteer service with NSU is contingent upon the findings of the screening. The following
questions must be answered truthfully. A “Yes” answer to any of the following questions does not automatically
keep you from being hired. Your omission or falsification of any criminal history, including juvenile
incidents, misdemeanors and/or felony will result in your immediate termination.
EXAMPLES OF CRIMINAL OFFENSES: Assault/battery, auto theft, disorderly conduct, domestic violence,
DUI/DWI, fraud (welfare/food stamps) loitering, prostitution/solicitation, robbery, shoplifting, theft (grand/
petty), trespassing, worthless checks. NOTE: This is not a complete list and is intended to provide
examples only. You must list all convictions including juvenile incidents and those in which adjudication
was withheld and/or records were sealed or expunged.
Yes
No
1.
Have you ever been convicted of a misdemeanor or felony offense other than a minor
traffic violation? Driving under the influence [DUI] and driving while intoxicated [DWI]
convictions are not minor and must be reported.
Yes No
2.
Have you ever been found guilty of a criminal offense?
Yes No
3.
Have you ever entered a nolo contendere or no contest plea in a criminal proceeding?
Yes No
4.
Have you ever had a criminal record sealed?
Yes No
5.
Have you ever had a criminal record expunged?
Yes
No
6.
Have you ever participated in any type of pre-trial intervention/diversion program,
including but not limited to community service or probation that resulted in the charges
being reduced/dismissed or not prosecuted?
Yes No
7.
Have you ever had adjudication withheld in a criminal offense?
Yes No
8.
Are there criminal charges currently pending against you?
Yes No
9.
Have you ever been imprisoned or jailed in a criminal proceeding?
Yes No
10.
Have you ever been placed on probation in a criminal proceeding?
Yes No
11.
Have you ever paid a fine in a criminal proceeding?
Yes
No
12.
Have you ever failed to appear in court or forfeited bond in a criminal proceeding?
IF YOU ANSWERED “YES” TO ANY QUESTIONS ABOVE, YOU MUST FULLY EXPLAIN INCIDENTS ON NEXT PAGE.
CRIMINAL CONVICTION SCREENING FORM-VOLUNTEER
IMPORTANT – READ BEFORE COMPLETING THIS FORM
Submit To OHR
Nova Southeastern University will receive information on all records, including juvenile that have been sealed, expunged, or
where adjudication was withheld. To omit a response or to be untruthful in your response, regardless of any
previous information received from an attorney, a judge, or any third party will be considered falsification and
is a cause for dismissal from employment or consideration for employment
2
Teachers are required to complete questions 13-16
Yes
No
13. Have you ever had a teaching certificate revoked or suspended? If yes, in what state
and when?_____________________________________________________________
Yes
No
14. Have you ever had sanctions placed on your teaching certificate for any reason?
Yes
No
15. Have you ever been denied a teaching certificate anywhere?
Yes No 16. Is disciplinary action currently pending anywhere against your teaching certificate?
IF YOU ANSWERED “YES” TO ANY OF THE QUESTIONS 1-16, YOU MUST FULLY EXPLAIN BELOW. BE SURE
TO GIVE THE NAME OF THE STATE IN WHICH YOUR TEACHING CERTIFICATE WAS REVOKED, SUSPENDED,
SANCTIONED, AND DENIED OR WHERE ACTION IS CURRENTLY PENDING AGAINST YOU.
INCIDENT #1
County of Adjudication: __________________________________Date of Adjudication: ________________
Agency: _______________________________________________________________________________
______________________________________________________________________________________
Offense: ______________________________________________________________________________
______________________________________________________________________________________
Please provide detailed explanation: ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Final disposition: ________________________________________________________________________
INCIDENT #2 (Attach more sheets if needed)
County of Adjudication: __________________________________Date of Adjudication:______________
Agency: _______________________________________________________________________________
______________________________________________________________________________________
Offense: _______________________________________________________________________________
______________________________________________________________________________________
Please provide detailed explanation: _________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Final disposition: _________________________________________________________________________
3
By signing this document I certify that I have carefully read and fully understand each question and
that all information contained herein is true and accurate. My signature further certifies that there is no
falsification of any information, omission of any information requested or any misrepresentation of
information requested. I also understand that my fingerprints will be submitted to the Federal Bureau
of Investigation for a complete criminal history background check
By my signature, I authorize Nova Southeastern University to conduct any investigation necessary to
verify all information identified on this form. My signature on this document provides for the release
of any sealed or expunged records in my name by any court. Included in this grant of authority is my
permission to contact any and all former employers and other persons acquainted with me or in
possession of information concerning me to supply such information to the Office of Human
Resources.
By my signature, I certify that I know, understand, and agree that any false statement or
omission of information requested will result in my immediate termination, with no
opportunity to grieve.
__________________________________ ____________________________
Signature Print Name
__________________________________
Date
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Criminal-conviction-screening-form-volunteer DONATION OF SICK LEAVE FORM

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Completed 16 November 2019

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