DOEA Form 236 "Affidavit of Compliance - Employee" - Florida

What Is DOEA Form 236?

This is a legal form that was released by the Florida Department of Elder Affairs - 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 April 1, 2016;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • 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 DOEA Form 236 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 236 "Affidavit of Compliance - Employee" - Florida

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BACKGROUND SCREENING
Affidavit of Compliance - Employee
AUTHORITY: This form is required of all employees who are direct service providers when
claiming an exception to Level 2 background screening set forth in sections 430.0402(2) and
(3), Florida Statutes, or to comply with the attestation requirements set forth in section
435.05(2), Florida Statutes.
This form may be used by all employees to comply with:
The attestation requirement of section 435.05(2), Florida Statutes, which states 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 408.809(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 435.12, Florida Statutes, 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, Florida Statutes, if that agency is not currently implemented in the
Care Provider Background Screening Clearinghouse.
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 license, please attach a copy of the screening results and submit the
licensure application.
The term “employee” as used herein refers collectively to all persons required by law to undergo background
screening. This includes, but is not limited to, persons who are determined to be a direct service provider. A direct
service provider is a person at least 18 years of age who, pursuant to a program to provide services to the elderly,
has direct face-to-face contact with a client while providing services and has access to the client’s living areas, funds,
personal property, or personal identification information as defined in F.S. 817.568, Florida Statutes. A direct service
provider also includes coordinators, managers, and supervisors of residential facilities and volunteers.
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 1 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
BACKGROUND SCREENING
Affidavit of Compliance - Employee
AUTHORITY: This form is required of all employees who are direct service providers when
claiming an exception to Level 2 background screening set forth in sections 430.0402(2) and
(3), Florida Statutes, or to comply with the attestation requirements set forth in section
435.05(2), Florida Statutes.
This form may be used by all employees to comply with:
The attestation requirement of section 435.05(2), Florida Statutes, which states 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 408.809(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 435.12, Florida Statutes, 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, Florida Statutes, if that agency is not currently implemented in the
Care Provider Background Screening Clearinghouse.
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 license, please attach a copy of the screening results and submit the
licensure application.
The term “employee” as used herein refers collectively to all persons required by law to undergo background
screening. This includes, but is not limited to, persons who are determined to be a direct service provider. A direct
service provider is a person at least 18 years of age who, pursuant to a program to provide services to the elderly,
has direct face-to-face contact with a client while providing services and has access to the client’s living areas, funds,
personal property, or personal identification information as defined in F.S. 817.568, Florida Statutes. A direct service
provider also includes coordinators, managers, and supervisors of residential facilities and volunteers.
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 1 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
Personal identification information defined in F.S. 817.568(1)(f), F.S. means “any name or number that may
be used, alone or in conjunction with any other information, to identify a specific individual, including any:
1. Name, postal or electronic mail address, telephone number, social security number, date of
birth, mother’s maiden name, official state-issued or United States-issued driver’s license or
identification number, alien registration number, government passport number, employer or
taxpayer identification number, Medicaid or food assistance account number, bank account
number, credit or debit card number, or personal identification number or code assigned to the
holder of a debit card by the issuer to permit authorized electronic use of such card;
2. Unique biometric data, such as fingerprint, voice print, retina or iris image, or other unique
physical representation;
3. Unique electronic identification number, address, or routing code;
4. Medical records;
5. Telecommunication identifying information or access device; or
6. Other number or information that can be used to access a person’s financial resources.”
EMPLOYER:
IF AN EMPLOYEE IS DETERMINED TO BE A DIRECT SERVICE PROVIDER, THIS COMPLETED
FORM MUST BE RETAINED IN THE EMPLOYEE’S FILE. IF AN EXCEPTION TO BACKGROUND SCREENING IS
CLAIMED, A COPY OF THE REQUIRED EVIDENCE MUST BE ATTACHED TO THIS FORM.
STEP ONE:
Complete identification information.
_________________________________________
_______________________________________
Employee Name
Position Applied For
______________________________________________________________________________________
Employer
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 2 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
STEP TWO:
The employee must review the following list of disqualifying offenses set forth
in Chapters 430 and 435, Florida Statutes.
You must attest to meeting the requirements for employment and you may not have been arrested
for and awaiting final disposition of, have been found guilty of, regardless of adjudication, or have
entered a plea of nolo contendere (no contest) or guilty to, or have been adjudicated delinquent and
the record has not been sealed or expunged for, any offense prohibited under any of the following
provisions of state law or similar law of another jurisdiction:
Criminal offenses listed in section 435.04, F.S.
(a) Section 393.135, relating to sexual misconduct
producing a child at a custody hearing or delivering
with certain developmentally disabled clients and
the child to the designated person.
reporting of such sexual misconduct.
(p) Section 790.115(1), relating to exhibiting firearms
(b) Section 394.4593, relating to sexual misconduct
or weapons within 1,000 feet of a school.
with certain mental health patients and reporting of
(q) Section 790.115(2)(b), relating to possessing an
such sexual misconduct.
electric weapon or device, destructive device, or
(c) Section 415.111, relating to adult abuse, neglect,
other weapon on school property.
or exploitation of aged persons or disabled adults.
(r) Section 794.011, relating to sexual battery.
(d) Section 782.04, relating to murder.
(s) Former s. 794.041, relating to prohibited acts of
(e) Section 782.07, relating to manslaughter,
persons in familial or custodial authority.
aggravated manslaughter of an elderly person or
(t) Section 794.05, relating to unlawful sexual activity
disabled adult, or aggravated manslaughter of a
with certain minors.
child.
(u) Chapter 796, relating to prostitution.
(f) Section 782.071, relating to vehicular homicide.
(v) Section 798.02, relating to lewd and lascivious
(g) Section 782.09, relating to killing of an unborn
behavior.
quick child by injury to the mother.
(w) Chapter 800, relating to lewdness and indecent
(h) Chapter 784, relating to assault, battery, and
exposure.
culpable negligence, if the offense was a felony.
(x) Section 806.01, relating to arson.
(i) Section 784.011, relating to assault, if the victim
(y) Section 810.02, relating to burglary.
of the offense was a minor.
(j) Section 784.03, relating to battery, if the victim of
(z) Section 810.14, relating to voyeurism, if the
the offense was a minor.
offense is a felony.
(k) Section 787.01, relating to kidnapping.
(aa) Section 810.145, relating to video voyeurism, if
the offense is a felony.
(l) Section 787.02, relating to false imprisonment.
(bb) Chapter 812, relating to theft, robbery, and
(m) Section 787.025, relating to luring or enticing a
related crimes, if the offense is a felony.
child.
(cc) Section 817.563, relating to fraudulent sale of
(n) Section 787.04(2), relating to taking, enticing, or
controlled substances, only if the offense was a
removing a child beyond the state limits with
felony.
criminal intent pending custody proceedings.
(dd) Section 825.102, relating to abuse, aggravated
(o) Section 787.04(3), relating to carrying a child
abuse, or neglect of an elderly person or disabled
beyond the state lines with criminal intent to avoid
adult.
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 3 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
(ee) Section 825.1025, relating to lewd or lascivious
(ww) Section 944.47, relating to introduction of
offenses committed upon or in the presence of an
contraband into a correctional facility.
elderly person or disabled adult.
(xx) Section 985.701, relating to sexual misconduct in
(ff) Section 825.103, relating to exploitation of an
juvenile justice programs.
elderly person or disabled adult, if the offense was a
(yy) Section 985.711, relating to contraband
felony.
introduced into detention facilities.
(gg) Section 826.04, relating to incest.
(ZZ) Section 741.28 relating to domestic violence.
(hh) Section 827.03, relating to child abuse,
Criminal offenses found in section 430.0402, F.S.
aggravated child abuse, or neglect of a child.
(a) Section 409.920, relating to Medicaid provider
(ii) Section 827.04, relating to contributing to the
fraud.
delinquency or dependency of a child.
(b) Section 409.9201, relating to Medicaid fraud.
(jj) Former s. 827.05, relating to negligent treatment
of children.
(c) Section 741.28, relating to domestic violence.
(kk) Section 827.071, relating to sexual performance
(d) Section 817.034, relating to fraudulent acts
by a child.
through mail, wire, radio, electromagnetic,
photoelectronic, or photooptical systems.
(ll) Section 843.01, relating to resisting arrest with
(e) Section 817.234, relating to false and fraudulent
violence.
insurance claims.
(mm) Section 843.025, relating to depriving a law
enforcement, correctional, or correctional probation
(f) Section 817.505, relating to patient brokering.
officer means of protection or communication.
(g) Section 817.568, relating to criminal use of
(nn) Section 843.12, relating to aiding in an escape.
personal identification information.
(oo) Section 843.13, relating to aiding in the escape
(h) Section 817.60, relating to obtaining a credit card
of juvenile inmates in correctional institutions.
through fraudulent means.
(pp) Chapter 847, relating to obscene literature.
(i) Section 817.61, relating to fraudulent use of credit
cards, if the offense was a felony.
(qq) Section 874.05(1), relating to encouraging or
(j) Section 831.01, relating to forgery.
recruiting another to join a criminal gang.
(k) Section 831.02, relating to uttering forged
(rr) Chapter 893, relating to drug abuse prevention
and control to include the use, possession, sale, or
instruments.
manufacturing of illegal drugs, only if the offense
(l) Section 831.07, relating to forging bank bills,
was a felony or if any other person involved in the
checks, drafts, or promissory notes.
offense was a minor.
(m) Section 831.09, relating to uttering forged bank
(ss) Section 916.1075, relating to sexual misconduct
bills, checks, drafts, or promissory notes.
with certain forensic clients and reporting of such
Criminal offenses found in other sections.
sexual misconduct.
(n) Section 775.21, sexual predator.
(tt) Section 944.35(3), relating to inflicting cruel or
inhuman treatment on an inmate resulting in great
(o) Section 775.261, Career offender.
bodily harm.
(p) Section 943.0435, Sexual offender; unless the
(uu) Section 944.40, relating to escape.
requirement to register as a sexual offender has
(vv) Section 944.46, relating to harboring,
been removed pursuant to section 943.04354.
concealing, or aiding an escaped prisoner.
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 4 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php
I have been granted an Exemption from Disqualification through the Agency for Healthcare
Administration (AHCA)
Date of Decision: __________________________
I have been granted an Exemption from Disqualification through the Florida Department of
Health.
Date of Decision: __________________________
** A copy of the Exemption from Disqualification decision letter must be attached**
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.
Purpose of Prior Screening: __________________________________________________________
Screening Conducted by: _________________________ Date of Prior Screening: _____________
Agency for Healthcare Administration
Department of Elder Affairs
Department of Health
Department of Financial Services
Agency for Persons with Disabilities
Department of Children and Family
Services
DOEA Form 236, Affidavit of Compliance - Employee, Effective April 2016
Section 435.05(2), F.S.
Page 5 of 7
Form available at:
http://elderaffairs.state.fl.us/english/backgroundscreening.php