Human Resources Last Revised 3/8/2018
Employee Information Exemption from Public Records Form
Pursuant to Chapter 119, Florida Statutes, it is the policy of this State that “every person who has custody
of a public record shall permit the record to be inspected and copied by any person desiring to do
so….providing access to public records is a duty of each agency.” Failure to submit this form timely may
result in disclosure of certain information, including your home address and telephone numbers (including
unlisted/unpublished numbers) and/or photograph, in response to a public records request.
All employees must complete and sign this form acknowledging that you are aware of the State Public
Records requirement under Florida Statute 119. In some circumstances, exemptions are allowed by law.
If you qualify for an exemption, please complete this form and provide required documentation. Human
Resources must have the complete form on file in order to:
1) To exclude (as exempt under Section 119.071, Florida Statutes) their home address and telephone
number, name, work locations, dates of birth (for most categories) and numbers for home phones,
personal cell phones, pagers and personal communication devices (and in many cases, their
photograph) from disclosure in response to public records requests (based on their own current/past
employment (as stated below) or being the spouse or child of a qualifying person), as well as
2) To exempt certain similar information, as specified in the Statute, from disclosure relating to their
spouse and children (including places of employment, names and locations of schools and day care
facilities attended by the children).
I DO NOT qualify for any of the exemptions below at this time. (NOTE: If you, your spouse, your
child(ren) or a child residing with you, do qualify for an exemption at some point in the future, notify
Human Resources by completing and submitting this form. It is the employee’s responsibility to notify
Human Resources in order to ensure that appropriate public records exemptions are applied.) If you
do not qualify, stop here, sign below, and submit this form to Human Resources.
Yes, I qualify for one of the exemption categories below (specify a category, by checking the
appropriate box):
1. Firefighter certified in compliance with Section 633.408, Florida Statutes (including certified
Forestry firefighter).
2. Current or former Judge or Justice of the Florida Supreme Court, a district court of appeal,
circuit court, or county court.
3. Active or former sworn or civilian law enforcement personnel.
4. Current or former correctional or correctional probation officer.
5. Current or former personnel of the Department of Children and Family Services whose duties
include the investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities.
6. Current or former personnel of the Department of Health whose duties are to support the
investigation of child abuse or neglect.
7. Current or former personnel of the Department of Revenue or local governments whose
responsibilities include revenue collection and enforcement of child support enforcement.
8. Current or former code-enforcement officer.
9. Current or former federal judge (U.S. Court of Appeals, U.S. District Court, or U.S. Magistrate
Judge).
Human Resources Last Revised 3/8/2018
10. Current or former state attorney, assistant state attorney, statewide prosecutor, or assistant
statewide prosecutor.
11. Current or former U.S. prosecutor (U.S. attorney or assistant U.S. attorney), Section
119.071(5), Florida Statutes.
12. Current or former Human Resources/Labor Relations/Employee Relations director, assistant
director, manager, or assistant manager of any local government agency or water management
district, whose duties include(d) hiring and firing employees, labor contract negotiation,
administration, or other personnel-related duties.
13. General magistrate, special magistrate, judge of compensation claims, administrative law judge
of the Division of Administrative Hearings, or child support enforcement hearing officer.
14. Current or former Guardians Ad Litem, under Section 39.820, Florida Statutes.
15. Current or former juvenile probation officers, juvenile probation supervisors, detention
superintendents, assistant detention superintendents, juvenile justice detention officers I and
II, juvenile justice detention officer supervisors, juvenile justice residential officers, juvenile
justice residential officer supervisors I and II, juvenile justice counselors, juvenile justice
counselor supervisors, human service counselor administrators, senior human services
counselor administrators, rehabilitation therapists, and social services counselors of the
Department of Juvenile Justice.
16. Current or former public defenders, assistant public defenders, criminal conflict and civil
regional counsel, or assistant criminal conflict and civil regional counsel.
17. Current or former investigators or inspectors of the Department of Business and Professional
Regulation.
18. Current or former member of the Armed Forces of the United States, a reserve component of
the Armed Forces of the United States, or the National Guard, who served after September 11,
2001.
19. Current or former impaired practitioner consultants (this program assists the Department of
Health and the Department of Business and Professional Regulation in determining whether
licensees who have experienced a substance abuse or mental or physical health impairment
are safe to practice) who are retained by an agency or current or former employees of an
impaired practitioner consultant whose duties result in a determination of a person’s skill and
safety to practice a licensed profession.
20. Current or former personnel of the Department of Health whose duties include, or result in, the
determination or adjudication of eligibility for social security disability benefits, the investigation
or prosecution of complaints filed against health care practitioners, or the inspection of health
care practitioners or health care facilities licensed by the Department of Health.
21. County tax collector.
22. Current or former non-sworn investigative personnel employed by the Department of Financial
Services whose duties include the investigation of fraud, theft, workers’ compensation coverage
requirements and compliance, other related criminal activities or state regulatory requirement
violations.
23. Current or former emergency medical technicians or paramedics certified under Chapter 401,
Florida Statutes.
24. Current or former personnel employed in an agency’s office of inspector general or internal
audit department whose duties included auditing or investigating waste, fraud, abuse, theft,
exploitation or other activities that could lead to criminal prosecution or administrative discipline.
EXEMPTION based on a category 1-24 above (select one):
I am the person described.
I am the spouse of the person described.
I am the child of a person described (except for Category 18).
Human Resources Last Revised 3/8/2018
A child living with me is the child of a person described (except for Category 18).
I am the dependent of a person described in Category 18.
A person living with me is a dependent of a person described in Category 18.
Specify the exact position title within the 24 categories listed above and the working location of this position
qualifying for any exemption(s) claimed above.
Position Title Work Location
I hereby certify that my answers herein are truthful and accurate; I understand that Section 837.06, Florida
Statutes, makes it a second-degree misdemeanor to knowingly make a false statement in writing with the
intent to mislead a public servant in the performance of his/her official duty. For employees who have
checked box numbers 9, 11, 13, 14, 17, 18, 19, 20, 21, 23, or 24 above, or who are claiming an exemption
through a person within any of those categories: I am also certifying by signing below that this is a
written statement certifying I have made reasonable efforts to protect such information from being
accessible through other means available to the public.
Signature of Employee Printed Name of Employee
Name of Person Entitled to Exemption Date
click to sign
signature
click to edit
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