CERTIFICATION OF GOOD MORAL CHARACTER - Florida

1 CERTIFICATION . OF GOOD. MORAL . CHARACTER . Authority: This form may be used by all employees to comply with: the attestation requirements of section (2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND. the proof of screening within the previous 5 years in section (2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider background screening Clearinghouse created under Section , , or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, , and in accordance with the standards in Section (2), , if that agency is not currently implemented in the Care Provider background screening Clearinghouse.

2 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 Employee/Contractor Name: license, please attach a copy of the screening results and submit with the licensure application. Health Care Provider/ Employer Name: Address of Health Care Provider: I hereby attest to meeting the requirements for employment and that I have not been arrested for or 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 following provisions of the Florida Statutes or under any similar statute of another jurisdiction: Criminal offenses found in section , (a) Section , relating to sexual (f) Section , relating to manslaughter, misconduct with certain developmentally aggravated manslaughter of an elderly person or disabled clients and reporting of such sexual disabled adult, or aggravated manslaughter of a misconduct.

3 Child. (b) Section , relating to sexual (g) Section , relating to vehicular misconduct with certain mental health patients homicide. and reporting of such sexual misconduct. (h) Section , relating to killing of an (c) Section , relating to adult abuse, unborn child by injury to the mother. neglect, or exploitation of aged persons or (i) Chapter 784, relating to assault, battery, and disabled adults. culpable negligence, if the offense was a felony. (d) Section , relating to attempts, (j) Section , relating to assault, if the solicitation, and conspiracy to commit an offense victim of the offense was a minor. listed in this subsection. (k) Section , relating to battery, if the (e) Section , relating to murder. victim of the offense was a minor. Page 1 of 4. Updated 3/11/2016. (l) Section , relating to kidnapping. was a felony. (m) Section , relating to false (hh) Section , relating to incest. imprisonment.

4 (ii) Section , relating to child abuse, (n) Section , relating to luring or enticing aggravated child abuse, or neglect of a child. a child. (jj) Section , relating to contributing to the (o) Section (2), relating to taking, delinquency or dependency of a child. enticing, or removing a child beyond the state (kk) Former s. , relating to negligent limits with criminal intent pending custody treatment of children. proceedings. (ll) Section , relating to sexual (p) Section (3), relating to carrying a performance by a child. child beyond the state lines with criminal intent to (mm) Section , relating to resisting arrest avoid producing a child at a custody hearing or with violence. delivering the child to the designated person. (nn) Section , relating to depriving a law (q) Section (1), relating to exhibiting enforcement, correctional, or correctional firearms or weapons within 1,000 feet of a school.

5 Probation officer means of protection or (r) Section (2)(b), relating to communication. possessing an electric weapon or device, (oo) Section , relating to aiding in an destructive device, or other weapon on school escape. property. (pp) Section , relating to aiding in the (s) Section , relating to sexual battery. escape of juvenile inmates in correctional (t) Former s. , relating to prohibited acts institutions. of persons in familial or custodial authority. (qq) Chapter 847, relating to obscene literature. (u) Section , relating to unlawful sexual (rr) Section , relating to encouraging or activity with certain minors. recruiting another to join a criminal gang. (v) Chapter 796, relating to prostitution. (ss) Chapter 893, relating to drug abuse (w) Section , relating to lewd and prevention and control, only if the offense was a lascivious behavior. felony or if any other person involved in the (x) Chapter 800, relating to lewdness and offense was a minor.

6 Indecent exposure. (tt) Section , relating to sexual (y) Section , relating to arson. misconduct with certain forensic clients and (z) Section , relating to burglary. reporting of such sexual misconduct. (aa) Section , relating to voyeurism, if the (uu) Section (3), relating to inflicting offense is a felony. cruel or inhuman treatment on an inmate resulting (bb) Section , relating to video in great bodily harm. voyeurism, if the offense is a felony. (vv) Section , relating to escape. (cc) Chapter 812, relating to theft, robbery, and (ww) Section , relating to harboring, related crimes, if the offense is a felony. concealing, or aiding an escaped prisoner. (dd) Section , relating to fraudulent sale (xx) Section , relating to introduction of of controlled substances, only if the offense was contraband into a correctional facility. a felony. (yy) Section , relating to sexual (ee) Section , relating to abuse, misconduct in juvenile justice programs.

7 Aggravated abuse, or neglect of an elderly person (zz) Section , relating to contraband or disabled adult. introduced into detention facilities. (ff) Section , relating to lewd or (3) The security background investigations lascivious offenses committed upon or in the under this section must ensure that no person presence of an elderly person or disabled adult. subject to this section has been found guilty of, (gg) Section , relating to exploitation of regardless of adjudication, or entered a plea of an elderly person or disabled adult, if the offense nolo contendere or guilty to, any offense that Page 2 of 4. Updated 3/11/2016. constitutes domestic violence as defined in s. provider. , whether such act was committed in this (k) Section , relating to patient state or in another jurisdiction. brokering. (l) Section , relating to criminal use of Criminal offenses found in section (4), personal identification information.

8 (m) Section , relating to obtaining a credit card through fraudulent means. (a) Any authorizing statutes, if the offense was (n) Section , relating to fraudulent use of a felony. credit cards, if the offense was a felony. (b) This chapter, if the offense was a felony. (o) Section , relating to forgery. (c) Section , relating to Medicaid (p) Section , relating to uttering forged provider fraud. instruments. (d) Section , relating to Medicaid (q) Section , relating to forging bank bills, fraud. checks, drafts, or promissory notes. (e) Section , relating to domestic (r) Section , relating to uttering forged violence. bank bills, checks, drafts, or promissory notes. (f) Section , relating to attempts, (s) Section , relating to fraud in obtaining solicitation, and conspiracy to commit an offense medicinal drugs. listed in this subsection. (t) Section , relating to the sale, (g) Section , relating to fraudulent acts manufacture, delivery, or possession with the through mail, wire, radio, electromagnetic, photo intent to sell, manufacture, or deliver any electronic, or photo optical systems.

9 Counterfeit controlled substance, if the offense (h) Section , relating to false and was a felony. fraudulent insurance claims. (u) Section , relating to racketeering and (i) Section , relating to obtaining goods collection of unlawful debts. by using a false or expired credit card or other (v) Section , relating to the Florida credit device, if the offense was a felony. Money Laundering Act. (j) Section , relating to fraudulently obtaining goods or services from a health care I also affirm that I have not been designated as a sexual predator pursuant to s. ; a career offender pursuant to s. ; or a sexual offender pursuant to s. , unless the requirement to register as a sexual offender has been removed pursuant to s. Attestation_____ __. Under penalty of perjury, I _____, hereby attest that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section , In addition, I agree to immediately inform my 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 I also understand that it is my responsibility to obtain clarification on anything contained in this affidavit which I do not understand prior to signing.

10 I am aware that any omissions, falsifications, misstatements or misrepresentations may disqualify me from employment consideration and, if I am hired, may be grounds for termination or denial of an exemption at a later date. _____ _____ _____. Employee/Contractor Signature Title Date Page 3 of 4. Updated 3/11/2016. To the best of my knowledge and belief, my record contains one or more of the applicable disqualifying acts or offenses listed above. (**If you have been granted an exemption from disqualification, a copy of the letter granting such exemption must be attached**). _____ _____ _____. Employee/Contractor Signature Title Date If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.