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Revised 10/14
Please make copies of all documents for your records.
Important Information for all Exemption Applicants
If you have not previously reported these offenses to the Board your file will be forwarded to our
Consumer Services office and your exemption application will be placed on hold. All investigations are
confidential and staff will not be able to provide you with any further information until you are contacted by an
investigator. If you need to report the offense, submit a detailed letter regarding the offense(s) or complete a
complaint form with the Consumer Services Unit and mail to: 4052 Bald Cypress Way, Bin C-75, Tallahassee,
FL 32399.
Chapter 435.07(3),F.S states, “…
the employee must demonstrate by clear and convincing evidence that
the employee should not be disqualified from employment.
Employees seeking an exemption have the
burden of setting forth sufficient evidence of rehabilitation, including, but not limited to, the circumstances
surrounding the criminal incident for which an exemption is sought, the time period that has elapsed since the
incident, the nature of the harm caused to the victim, and the history of the employee since the incident, or any
other evidence or circumstances indicating that the employee will not present a danger if continued
employment is allowed…”.
All licensees with any offense listed in chapter
408.809
Florida Statutes must also apply for an exemption.
If you have a
Felony Disqualifying Offense
, and you have not completed or been lawfully released from
confinement, supervision, or non-monetary conditions imposed by the court for the disqualifying felony in the
last 3 years, you will not qualify for an exemption. All disqualifying offenses (felonies and misdemeanors)
that have adjudication withheld will be handled the same as a conviction for the purposes of this exemption
request.
In order to qualify for an exemption, you must have paid any amount for any fee, fine, fund, lien, civil
judgement, application, cost of prosecution, trust, or restitution as part of the judgement and sentence for
any disqaulfying felony or misdemeanor in full.
All requested information must be submitted before a determination can be made.The appropriate Board
within the Department of Health will make notification when a decision related to the request is made.
Mail the application and any required documents to:
Florida Board of Nursing
4052 Bald Cypress Way, BIN C-02
Tallahassee, Florida 32399-3252
You must hold a valid, active license to be eligible for an exemption.
If you
do not have a license you must apply for an exemption with the Agency for Health Care
Administration. If you are in the process of applying for a license you do not need to fill out the exemption
application separately, you may include a note in your application that you will need an exemption and we
will handle it as we process your application for licensure.
1. Sexual predator as designated pursuant to s. 775.21;
2. Career offender pursuant to s. 775.261 ; or
3. Sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has
been removed pursuant to s. 943.04354
.
An exemption cannot be issued to any person who is a:
1
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Revised 10/14
Exemption Checklist
IT IS IMPORTANT TO PROVIDE ALL THE INFORMATION BELOW AND CHECK EACH ITEM
AS YOU OBTAIN IT…
Agency for Health Care Administration (AHCA) Level II Screening- Licensees who have completed
a Level II screening with AHCA within the last three (3) months are not required to complete Livescan
fingerprints. Please note: In the event we cannot verify your screening with AHCA, you will be
required to complete the Live Scan requirement.
Livescan- The Department of Health only accepts electronic fingerprinting offered by Livescan
service providers that are approved by the Florida Department of Law Enforcement.
http://www.floridahealth.gov/licensing-and-regulation/background-screening/livescan-service-providers.html
Our ORI number is EDOH0380Z.
Court Disposition(s)- You must submit documentation from the county Clerk of Courts in the
jurisdiction (state/county) in which the offense(s) occurred, including disposition/final results.
Arrest Report(s)- You must submit a copy of the arrest report for each offense.You may obtain a copy
of this report from the arresting agency (Police or Sheriff's Department).
Probation/Parole or PTI Letter(s)- You must submit proof of completion of all court ordered
office and must include the start date and termination date of your probation.
Recommendation Letters- You must submit three (3) current (written within the last year) letters
of professional recommendation on official letterhead from employers, nursing program administrators,
Proof of Rehabilitation- You must submit proof of rehabilitation which may include letters
or training, special awards or recognition, or documentation that indicates you are not a danger to the
safety or well being of others.
OR
Self-Explanation- You must submit a letter in your own words describing in detail the circumstances
how you demonstrate by clear and convincing evidence that you should not be disqualified from employment.
surrounding each offense; including date, city and state, charges and final results. This letter must include
nursing instructors, health professionals, professional counselors, support group sponsors, parole or
probation officers, or other individuals in positions of authority who are familiar with your past and present
character.
from employer’s records of successful participation in a rehabilitation program(s), further education
probation/parole or PTI (Pre-trial intervention). This documentation must be issued by the probation
A description of any violation of probation must be included in this letter.
2
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Revised 10/14
Florida Board of Nursing
4052 Bald Cypress Way, Bin C-02
Tallahassee, FL 32399
Phone: (850) 245-4125
I am formally requesting the Department of Health, in accordance with the provision of Chapter 435, provide me with an exemption
review. I understand that I must provide clear and convincing evidence to support a reasonable belief that I am of good moral
character and that I pose no danger to the health or safety of patients.
I also understand that the decision of the Department of Health regarding this exemption may be contested through a hearing
under the provisions of Chapter 120,F.S.
I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention
privacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the Federal
Bureau of Investigation. (Found in Forms Section of this application).
Exemption Application
Certified Nursing Assistant (CNA) 4401
Fax: (850) 617-6460
Website: www.floridasnursing.gov
Email: MQA.CNA@flhealth.gov
Please complete this application in
its entirety prior to printing.
I have completed a Level II background screening with the Agency for Health Care Administration (AHCA)
in the last three (3) months.
I have NOT been subjected to a Level II background screening. (Livescan required)
Background Screening: (Check one only)
Profession Type:
You must hold a active Florida license to qualify for an exemption.
Name:
First
Middle
Mailing Address:
Apt. No.
City
State
Zip
Country
Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website.)
Apt./Suite No.
City
State
Zip
Country
Home/Cell Telephone (Input without dashes)
Work/Cell Telephone (Input without dashes)
Last/Surname
Street/P.O. Box
Street
Florida License Number:
Social Security Number:
Email Address:
Sex:
Race:
Applicant's Signature
Date
This field cannot be typed. You must print out the application and sign it.
MM/DD/YYYY
MM/DD/YYYY
Date of Birth:
3
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Revised 10/14
Electronic Fingerprinting
Name:
Social Security Number:
Date of Birth:
Citizenship:
Sex:
(MM/DD/YYYY)
(M=Male; F=Female)
Race:
Height:
(W-White/Latino(a); B-Black; A-Asian; NA-Native American; U-Unknown)
Aliases:
Place of Birth:
Weight:
Eye Color:
Hair Color:
Address:
Apt. Number:
City:
State:
Zip Code:
Transaction Control Number (TCN#):
(This will be provided to you by the Live Scan Vendor.)
You will need to keep this form for your records. Do not send this form to the Board Office.
Take this form with you to the Livescan service provider. Please check the service provider's
requirements to see if you need to bring any additional items.
• Background screening results are obtained from the Florida Department of Law Enforcement and
• If you obtain your Livescan from a service provider who does not capture your photo you may be
•
The ORI number for the Board of Nursing is: EDOH0380Z.
• Typically background screening results submitted through a Livescan service provider are
• You must provide accurate demographic information to the Livescan service provider at the
• If you do not provide the correct Originating Agency Identification (ORI) number to the Livescan
• Out of State/Country Livescan directions are included in the electronic fingerprinting section of this
• You can find a Livescan service provider at: http://www.floridahealth.gov/mqa/background.html;
the Federal Bureau of Investigation by submitting to a fingerprint scan using the Livescan method;
application.
service provider the Board office will not receive your background screening results;
time your fingerprints are taken, including your Social Security number (SSN);
received by the Board within 24-72 hours of being processed.
required to be reprinted by another agency in the future.
• Livescan screenings done by a Florida Police or Sheriff's Department require that you login to the
FDLE Civil Applicant Payment System (CAPS) at https://caps.fdle.state.fl.us and pay a fee before
results will be released to our office.
4
Page
Revised 10/14
Until the criminal history background check is completed, you may be denied unsupervised access to children,
the elderly, or persons with disabilities.
The FBI's Privacy Statement follows on a separate page and contains additional information.
FLORIDA DEPARTMENT OF LAW ENFORCEMENT
NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILL
BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSE
NOTICE OF:
• SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,
• RETENTION OF FINGERPRINTS,
• PRIVACY POLICY, AND
This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law
Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history
records that may pertain to you, the results of that search will be returned to the Care Provider Background
Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and
national criminal history record that may pertain to you to the Specified Agency or Agencies from which you are
seeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to the
National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency"
means the Department of Health, the Department of Children and Family Services, the Division of Vocational
Rehabilitation within the Department of Education, the Agency for Health Care Administration, the Department
of Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when these
agencies are conducting state and national criminal history background screening on persons who provide
care for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLE
and the Clearinghouse will be notified if FDLE receives Florida arrest information on you.
Your Social Security Number (SSN) is needed to keep records accurate because other people may
have the same name and birth date. Disclosure of your SSN is imperative for the performance of the
Clearinghouse agencies' duties in distinguishing your identity from that of other persons whose
identification information may be the same as or similar to yours.
• RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD
Licensing and employing agencies are allowed to release a copy of the state and national criminal record
information to a person who requests a copy of his or her own record if the identification of the record was based
on submission of the person's fingerprints. Therefore, if you wish to review your record, you may request that
the agency that is screening the record provide you with a copy. After you have reviewed the criminal history
record, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s.
943.056, F.S., and Rule 11C-8.001, F.A.C. If national information is believed to be in error, the FBI should be
contacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directly
from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination as
to the validity of your challenge before a final decision is made about your status as an employee, volunteer,
contractor, or subcontractor.
5
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Revised 10/14
Additional Information: The requesting agency and/or the agency conducting the application investigation will
provide you additional information pertinent to the specific circumstances of this application, which may include
identification of other authorities, purposes, uses, and consequences of not providing requested information. In
addition, any such agency in the Federal Executive Branch has also published notice.
Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent,
and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5
USC 552a(b)) and all applicable routine uses as many be published at any time in the Federal Register, including
the routine uses for the FBI Fingerprint Identification Records System (Justice, FBI-009) and the FBI's Blanket
Routine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to, disclosures to: appropriate
governmental authorities responsible for civil or criminal law enforcement counterintelligence, national security or
public safety matters to which the information may be relevant; to State and local governmental agencies and
nongovernmental entities for application processing as authorized by Federal and State legislation, executive
order, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized
by law , treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing
the application, they may have additional routine uses.
Principal Purpose: Certain determinations, such as employment, security, licensing and adoption, may be
predicated on fingerprint based checks. Your fingerprints and other information contained on (and along with) this
form may be submitted to the requesting agency, the agency conducting the application investigation, and/or FBI
for the purpose of comparing the submitted information to available records in order to identify other information
that may be pertinent to the application. During the processing of this application, and for as long hereafter as my
be relevant to the activity for which this application is being submitted, the FBI( may disclose any potentially
pertinent information to the requesting agency and/or to the agency conducting the investigation. The FBI may
also retain the submitted information in the FBI's permanent collection of fingerprints and related information,
where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature of
your application, the requesting agency and/or the agency conducting the application investigation may also retain
the fingerprints and other submitted information for other authorized purposes of such agency(ies).
Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people
may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the
requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory
or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks
Federal Agencies to use this number to help identify individuals in agency records.
Authority: The FBI's acquisition, preservation and exchange of information requested by this form is generally
authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include
numerous Federal statutes, hundreds of State statutes pursuant to Pub.L.92-544, Presidential executive orders,
regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examples
include, but are not limited to: 5 U.S.C. 9101; Pub.L.94-29; Pub.L.101-604; and Executive Orders 10450 and
12968. Providing the requested information is voluntary; however, failure to furnish the information may affect
timely completion of approval of your application.
PRIVACY STATEMENT
US Department of Justice, Federal Bureau of Investigation
Criminal Justice Information Services Division
6
Page
Revised 10/14
435.04 Level 2 screening standards—
(1)(a) All employees required by law to be screened pursuant to this section must undergo security background
investigations as a condition of employment and continued employment which includes, but need not be limited
to, fingerprinting for statewide criminal history records checks through the Department of Law Enforcement, and
criminal records checks through local law enforcement agencies.
(b) Fingerprints submitted pursuant to this section on or after July 1, 2012, must be submitted electronically to the
Department of Law Enforcement.
(c) An agency may contract with one or more vendors to perform all or part of the electronic fingerprinting pursuant to
this section. Such contracts must ensure that the owners and personnel of the vendor performing the electronic
fingerprinting are qualified and will ensure the integrity and security of all personal information.
(d) An agency may require by rule that fingerprints submitted pursuant to this section must be submitted electronically to
the Department of Law Enforcement on a date earlier than July 1, 2012.
The security background investigations under this section must ensure that no persons subject to the provisions of
this section have been arrested for and are awaiting final disposition of, have been found guilty of, regardless of
adjudication, or entered a plea of nolo contendere or guilty to, or have been adjudicated delinquent and the record
similar law of another jurisdiction:
(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
(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
(e) Section 782.04 , relating to murder.
(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or
aggravated manslaughter of a child.
(g) Section 782.071, relating to vehicular homicide.
(h) Section 782.09, relating to killing of an unborn quick 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.
(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
(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.
national criminal history records checks through the Federal Bureau of Investigation, and may include local
(2)
has not been sealed or expunged for, any offense prohibited under any of the following provisions of state law or
7
Page
(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.
(d) Section 777.04, relating to attempts, solicitation, and conspirarcy to commit an offense listed in this subsection.
misconduct.
custody proceedings.
Revised 10/14
(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
435.07 Exemptions from disqualification—
Unless otherwise provided by law, the provisions of this section apply to exemptions from disqualification for disqualifying
offenses revealed pursuant to background screenings required under this chapter, regardless of whether those
disqualifying offenses are listed in this chapter or other laws.
(1) The head of the appropriate agency may grant to any employee otherwise disqualified from employment an exemption
from disqualification for:
(a) Felonies for which at least 3 years have elapsed since the applicant for the exemption has completed or been lawfully
released from confinement, supervision, or non-monetary conditions imposed by the court for the disqualifying felony;
(b) Misdemeanors prohibited under any of the statutes cited in this chapter or under similar statutes of other jurisdictions
for which the applicant for the exemption has completed or been lawfully released from confinement, supervision, or
non-monetary condition;
(c) Offenses that were felonies when committed but that are now misdemeanors and for which the applicant for the
exemption has completed or been lawfully released from confinement, supervision, or non-monetary condition; or
(d) Findings of delinquency. For offenses that would be felonies if committed by an adult and the record has not been
sealed or expunged, the exemption may not be granted until at least 3 years have elapsed since the applicant for the
exemption has completed or been lawfully released from confinement, supervision, or non-monetary conditions
imposed by the court for the disqualifying offense.
For the purposes of this subsection, the term “felonies” means both felonies prohibited under any of the statutes cited in
this chapter or under similar statutes of other jurisdictions.
(2) Persons employed, or applicants for employment, by treatment providers who treat adolescents 13 years of age and
older who are disqualified from employment solely because of crimes under s. 817.563, s. 893.13, or s. 893.147 may
be exempted from disqualification from employment pursuant to this chapter without application of the waiting period in
paragraph (1)(a).
8
Page
(3)(a) In order for the head of an agency to grant an exemption to any employee, the employee must demonstrate by
clear and convincing evidence that the employee should not be disqualified from employment. Employees seeking
an exemption have the burden of setting forth clear and convincing evidence of rehabilitation, including, but not limited
to, the circumstances surrounding the criminal incident for which an exemption is sought, the time period that has
elapsed since the incident, the nature of the harm caused to the victim, and the history of the employee since the
incident, or any other evidence or circumstances indicating that the employee will not present a danger if employment
or continued employment is allowed.
(b) The agency may consider as part of its deliberations of the employee’s rehabilitation the fact that the employee has,
subsequent to the conviction for the disqualifying offense for which the exemption is being sought, been arrested
for or convicted of another crime, even if that crime is not a disqualifying offense.
(c) The decision of the head of an agency regarding an exemption may be contested through the hearing procedures
or guilty forth in chapter 120. The standard of review by the administrative law judge is whether the agency’s intended
action is an abuse of discretion.
(4)(a) Disqualification from employment under this chapter may not be removed from, nor may an exemption be granted
to, any personnel who is found guilty of, regardless of adjudication, or who has entered a plea of nolo contendere
or guilty to, any felony covered by s. 435.03 or s. 435.04 solely by reason of any pardon, executive clemency, or
restoration of civil rights.
(b) Disqualification from employment under this chapter may not be removed from, nor may an exemption be granted
to, any person who is a:
1. Sexual predator as designated pursuant to s. 775.21;
2. Career offender pursuant to s. 775.261; or
3. Sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed
pursuant to s. 943.04354
(5) Exemptions granted by one agency shall be considered by subsequent agencies, but are not binding on the
subsequent agency.
408.809 Background screening; prohibited offenses.—
(1) Level 2 background screening pursuant to chapter 435 must be conducted through the agency on each of the
following persons, who are considered employees for the purposes of conducting screening under chapter 435:
(a) The licensee, if an individual.
(b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider.
(c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or
provider.
(d) Any person who is a controlling interest if the agency has reason to believe that such person has been convicted of
any offense prohibited by s. 435.04. For each controlling interest who has been convicted of any such offense, the
licensee shall submit to the agency a description and explanation of the conviction at the time of license application.
(e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to,
or whose responsibilities may require him or her to, provide personal care or services directly to clients or have
access to client funds, personal property, or living areas; and any person, as required by authorizing statutes,
contracting with a licensee or provider whose responsibilities require him or her to provide personal care or
personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s
(2) Every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection
(1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background
rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such
rescreening, the agency shall request the Department of Law Enforcement to forward the person’s fingerprints to the
Federal Bureau of Investigation for a national criminal history record check. If the fingerprints of such a person are not
retained by the Department of Law Enforcement under s. 943.05(2)(g), the person must file a complete set of fingerprints
with the agency and the agency shall forward the fingerprints to the Department of Law Enforcement for state processing,
and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national
criminal history record check. The fingerprints may be retained by the Department of Law Enforcement under s.
943.05(2)(g). The cost of the state and national criminal history records checks required by level 2 screening may be
borne by the licensee or the person fingerprinted. Proof of compliance with level 2 screening standards submitted within
the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health,
the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial
employer or the licensee.
Revised 10/14
Page 9
Revised 10/14
Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care
retirement community under chapter 651 satisfies the requirements of this section if the person subject to screening has
not been unemployed for more than 90 days and such proof is accompanied, under penalty of perjury, by an affidavit of
compliance with the provisions of chapter 435 and this section using forms provided by the agency.
(3) All fingerprints must be provided in electronic format. Screening results shall be reviewed by the agency with respect to
the offenses specified in s. 435.04 and this section, and the qualifying or disqualifying status of the person named in the
request shall be maintained in a database. The qualifying or disqualifying status of the person named in the request shall
be posted on a secure website for retrieval by the licensee or designated agent on the licensee’s behalf.
(4) In addition to the offenses listed in s. 435.04, all persons required to undergo background screening pursuant to this
part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of,
regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated
delinquent and the record not have been sealed or expunged for any of the following offenses or any similar offense of
another jurisdiction:
(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.
(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.
(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.
(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.
any counterfeit controlled substance, if the offense was a felony.
10
Page
(f) Section 777.04, relating to attempts, solicititation, and conspiracy to commit an offense listed in this subsection.
(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 fraudlently obtaining goods or services from a health care provider.
(u) Section 895.03, relating to racketeering and collection of unlawful debts.
(v) Section 896.101, relating to the Florida Money Laundering Act.
(o) Section 831.01, relating to forgery.
(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
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Completed 15 February 2022

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