Form IG/BSU-005 "Request for Clearinghouse Screening for Provider Volunteer" - Florida

What Is Form IG/BSU-005?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IG/BSU-005 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Form IG/BSU-005 "Request for Clearinghouse Screening for Provider Volunteer" - Florida

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IG/BSU-005
Revised 10/2021
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE
CLEARINGHOUSE
REQUEST FOR
SCREENING
VOLUNTEER
FOR PROVIDER
Detention
Residential
Probation
Prevention
Research
Other
_________________
Check one of the screening types below
Initial Screening
Provider Share
Agency Review
Resubmission
Renewal
Check this box if the applicant is or was
a Florida law enforcement officer or certified officer with the Department of Corrections.
A.
Last Name
First Name
Full Middle Name
Maiden/Alias
Social Security #:
Race/Sex:
DOB:
Screening Request ID#
Driver’s License #:
Email Address:
B. TO BE COMPLETED BY REQUESTOR
Requestor’s Name (Contact Person)
Telephone Number & Ext. #
Fax Number
_________________________________________________
Office/Facility/Program Name
Email Address (write legibly or type)
C. FOR BSU PERSONNEL USE ONLY
(Do not write below this line)
“Public Rap Sheet”
button to view the applicant’s Florida criminal record.
Providers must check the Clearinghouse Portal for Results and click the
Provider Share
The BSU will fax or e-mail the
Public Rap Sheet
to the provider when the screening type is
.
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
Until __________
DHSMV records can be check by visiting http://www.hsmv.state.fl.us.
Eligibility Determination:
Eligible
Not Eligible
Florida Criminal Record:
Yes (Attached)
No
Judicial Inquiry System:
Yes (See Applicant)
No
Hot File:
*W
Yes (See Applicant)
No
arrant-Protection Order-Probation
Hot File –Identified Risk:
*
Violent Felony Offender-Career or Habitual
Yes (See Rap Sheet)
No
Offender- Sexual Offender- Sexual Predator
Subject of DJJ Reportable Incident:
Yes (Attached)
No
Automated Training Management
System (ATMS):
Yes (Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date:
IG/BSU-005
Revised 10/2021
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE
CLEARINGHOUSE
REQUEST FOR
SCREENING
VOLUNTEER
FOR PROVIDER
Detention
Residential
Probation
Prevention
Research
Other
_________________
Check one of the screening types below
Initial Screening
Provider Share
Agency Review
Resubmission
Renewal
Check this box if the applicant is or was
a Florida law enforcement officer or certified officer with the Department of Corrections.
A.
Last Name
First Name
Full Middle Name
Maiden/Alias
Social Security #:
Race/Sex:
DOB:
Screening Request ID#
Driver’s License #:
Email Address:
B. TO BE COMPLETED BY REQUESTOR
Requestor’s Name (Contact Person)
Telephone Number & Ext. #
Fax Number
_________________________________________________
Office/Facility/Program Name
Email Address (write legibly or type)
C. FOR BSU PERSONNEL USE ONLY
(Do not write below this line)
“Public Rap Sheet”
button to view the applicant’s Florida criminal record.
Providers must check the Clearinghouse Portal for Results and click the
Provider Share
The BSU will fax or e-mail the
Public Rap Sheet
to the provider when the screening type is
.
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
Until __________
DHSMV records can be check by visiting http://www.hsmv.state.fl.us.
Eligibility Determination:
Eligible
Not Eligible
Florida Criminal Record:
Yes (Attached)
No
Judicial Inquiry System:
Yes (See Applicant)
No
Hot File:
*W
Yes (See Applicant)
No
arrant-Protection Order-Probation
Hot File –Identified Risk:
*
Violent Felony Offender-Career or Habitual
Yes (See Rap Sheet)
No
Offender- Sexual Offender- Sexual Predator
Subject of DJJ Reportable Incident:
Yes (Attached)
No
Automated Training Management
System (ATMS):
Yes (Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date: