DJJ Form IG/BSU-003 "Criminal History Acknowledgement and Prison Rape Elimination Act (Prea) Compliance Form" - Florida

What Is DJJ Form IG/BSU-003?

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 April 1, 2016;
  • 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;

Download a fillable version of DJJ Form IG/BSU-003 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form IG/BSU-003 "Criminal History Acknowledgement and Prison Rape Elimination Act (Prea) Compliance Form" - Florida

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BSU FAX: (850) 921-6348 or (850) 922-7997
BSU EMAIL: Generalbsu@djj.state.fl.us
IG/BSU-003
Revised 4/16
DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
CRIMINAL HISTORY ACKNOWLEDGEMENT AND PRISON RAPE ELIMINATION ACT
(PREA) COMPLIANCE FORM
(print applicant’s name)
__________________________________
, as an applicant for employment or volunteer with,
_____________________________________
which may include responsibilities as a caretaker and/or direct
(print program name),
contact staff, I certify that I meet the requirements for employment as caretaker, as required by Federal and Florida Statutes and
rules, in that:
A.
In accordance with the Prison Rape Elimination Act (PREA) (115.317) we are unable to employ or utilize
as a volunteer individuals who have (1) engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other Institution (as defined in 42 U.S. C. 1997); (2) been
convicted of engaging or attempting to engage in sexual activity in the community facilitated by force,
overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or
refuse; or (3) been civilly or administratively adjudicated to have engaged in the activity described in (1-
3) of this section.
1
Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
a) Yes
b) No
2
Have you been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent
or was unable to consent or refuse?
a) Yes
b) No
3
Have you been civilly or administratively adjudicated to have engaged in the activity described in
questions one and two above?
a) Yes
b) No
I have read the above carefully and certify that the information is true and correct. I understand that it
is my responsibility to obtain clarification on anything contained in this section that I do not
understand prior to signing. I am aware that any omissions, falsifications, misstatements or
misrepresentations may disqualify me from consideration as an employee or volunteer and, if I am
hired or being utilized as a volunteer, may be grounds for termination at a later date.
__________________________________________
__________________________________________
APPLICANT SIGNATURE and DATE
WITNESS SIGNATURE and DATE
Page 1 of 4
BSU FAX: (850) 921-6348 or (850) 922-7997
BSU EMAIL: Generalbsu@djj.state.fl.us
IG/BSU-003
Revised 4/16
DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
CRIMINAL HISTORY ACKNOWLEDGEMENT AND PRISON RAPE ELIMINATION ACT
(PREA) COMPLIANCE FORM
(print applicant’s name)
__________________________________
, as an applicant for employment or volunteer with,
_____________________________________
which may include responsibilities as a caretaker and/or direct
(print program name),
contact staff, I certify that I meet the requirements for employment as caretaker, as required by Federal and Florida Statutes and
rules, in that:
A.
In accordance with the Prison Rape Elimination Act (PREA) (115.317) we are unable to employ or utilize
as a volunteer individuals who have (1) engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other Institution (as defined in 42 U.S. C. 1997); (2) been
convicted of engaging or attempting to engage in sexual activity in the community facilitated by force,
overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or
refuse; or (3) been civilly or administratively adjudicated to have engaged in the activity described in (1-
3) of this section.
1
Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
a) Yes
b) No
2
Have you been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent
or was unable to consent or refuse?
a) Yes
b) No
3
Have you been civilly or administratively adjudicated to have engaged in the activity described in
questions one and two above?
a) Yes
b) No
I have read the above carefully and certify that the information is true and correct. I understand that it
is my responsibility to obtain clarification on anything contained in this section that I do not
understand prior to signing. I am aware that any omissions, falsifications, misstatements or
misrepresentations may disqualify me from consideration as an employee or volunteer and, if I am
hired or being utilized as a volunteer, may be grounds for termination at a later date.
__________________________________________
__________________________________________
APPLICANT SIGNATURE and DATE
WITNESS SIGNATURE and DATE
Page 1 of 4
B. This section is used to determine if the applicant or employee has a criminal offense(s) that
would disqualify him or her from employment or to be used as a volunteer
(Note: If the applicant
.
or employee was previously granted an exemption from the Department for a disqualifying offense, attach
a copy of the exemption letter.)
1.
In accordance with Florida Statutes 435.04, 985.644 and 985.66, I acknowledge the following:
1)
I have not been judicially determined to have committed abuse or neglect against a child as
defined in s.39.01.
2)
I have not committed an act which constitutes domestic violence as defined in Sections 741.28
and 741.30 (domestic violence is defined as any crime of violence against a family/household
member, including assault and battery).
3)
I have not been found guilty, regardless of whether adjudication was imposed or withheld, of
any of the offenses listed below, or of any similar offense in another jurisdiction. This statement
does not apply to juvenile records that are sealed or expunged.
4)
I have not entered a plea of guilty or nolo contendere (no contest), or had the court enter such a
plea, to any of the offenses listed below, or to any similar offense in another jurisdiction. This
statement does not apply to juvenile records that are sealed or expunged.
5)
I have not entered a plea of nolo contendere (no contest), or other plea amounting to an
admission of guilt, to a petition alleging delinquency under Florida Statutes, or under a similar
statute of another jurisdiction for any of the offenses listed below, regardless of whether
adjudication was imposed or withheld and regardless of disposition. This statement does not
apply to juvenile records that are sealed or expunged.
6)
I do not have a delinquency record that is similar to any of the offenses listed below.
2.
I understand that I must immediately notify my employer of any possible disqualifying offenses,
which may occur while employed or volunteering in a caretaker and/or direct contact position.
Failure to do so could be grounds for termination.
3.
Circle the
The statements referenced in this section are related to the following Florida Statutes.
number next to the offense(s) that may appear in your criminal record
:
1. 393.135
relating to sexual misconduct with certain developmentally disabled
clients and reporting of such sexual misconduct.
2. 394.4593
relating to sexual misconduct with certain mental health patients and
reporting of such sexual misconduct.
3. 415.111
relating to adult abuse, neglect, or exploitation of aged person
or disabled adults
4. 741
relating to domestic violence as defined in Sections 741.28 and
741.30 (any crime of violence against a family/household
member, including assault and battery).
5. 777.04
relating to attempts, solicitation, and conspiracy to commit an offense
listed in this subsection
6. 782.04
relating to murder
7. 782.07
relating to manslaughter, aggravated manslaughter of an elderly
person or disabled adult, or aggravated manslaughter of a child
8. 782.071
relating to vehicular homicide
9. 782.09
relating to killing of an unborn child by injury to the mother
10. 784
relating to assault, battery, and culpable negligence, if the offense was
a felony.
11. 784.011
relating to assault, if the victim of the offense was a minor
12. 784.021
relating to aggravated assault
13. 784.03
relating to battery, if the victim of the offense was a minor
14. 784.045
relating to aggravated battery
15. 784.07
relating to assault or battery of law enforcement officers,
Fire fighters, emergency medical care providers, public transit
Page 2 of 4
employees or agents, or other specified officers
16. 784.075
relating to battery on a detention or commitment facility staff
17. 787.01
relating to kidnapping
18. 787.02
relating to false imprisonment
19. 787.025
relating to luring or enticing a child.
20. 787.04(2) relating to taking, enticing, or removing a child beyond the state
limits with criminal intent pending custody proceedings
21. 787.04(3) relation 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
22. 790.115(1) relating to exhibiting firearms or weapons within 1,000 feet of a
School
23.
relating to possessing an electric weapon or device, destructive
790.115(2)(b)
device, or other weapon on school property
24. 794.011
relating to sexual battery
25. 794.041
relating to prohibited acts of persons in familial or custodial authority
26. 794.05
relating to unlawful sexual activity with certain minors.
27. 796
relating to prostitution
28. 798.02
relating to lewd and lascivious behavior
29. 800
relating to lewdness and indecent exposure
30. 806.01
relating to arson
31. 810.02
relating to burglary
32. 810.14
relating to voyeurism, if the offense is a felony.
31. 810.145
relating to video voyeurism, if the offense is a felony.
32. 812
relating to theft, robbery and related crimes, if the offense was a
felony
33. 817.563
relating to fraudulent sale of controlled substances, only if the offense
was a felony
34. 817.568
relating to criminal use of personal identification information
35. 825.102
relating to abuse, aggravated abuse, or neglect of an elderly person or
disabled adult
36. 825.1025
relating to lewd or lascivious offenses committed upon or in the
presence of an elderly person or disabled adult
37. 825.103
relating to exploitation of an elderly person or disabled adult, if the
offense was a felony
38. 826.04
relating to incest
39. 827.03
relating to child abuse, aggravated child abuse, or neglect of a child
40. 827.04
relating to contributing to the delinquency or dependency of a child
41. 827.05
relating to negligent treatment of children
42. 827.071
relating to sexual performance by a child
43. 837.012
relating to perjury when not in an official proceeding
44. 837.05
relating to false reports to law enforcement authorities*
45. 837.055
relating to false information to law enforcement during investigation*
46. 837.06
relating to false official statements*
(*Note: Any person who pled nolo contendere to a
misdemeanor involving a false statement before October 1, 1999, and who has had that record sealed or
expunged is not disqualified for employment.)
47. 843.01
relating to resisting arrest with violence
48. 843.025
relating to depriving a law enforcement, correctional, or correctional
probation officer means of protection or communication
49. 843.12
relating to aiding in an escape
50. 843.13
relating to aiding in the escape of juvenile inmates in correctional
institutions
51. 847
relating to obscene literature
52. 874.05
relating to encouraging or recruiting another to join a criminal gang
53. 893
relating to drug abuse prevention and control if the offense was a
felony or if any other person involved in the offense was a minor (this
Page 3 of 4
includes charges of possession of controlled substances, the sale of
controlled substances, intent to sell controlled substances, trafficking
in controlled substances, and possession of drug paraphernalia, etc.)
54. 916.1075 relating to sexual misconduct with certain forensic clients and
reporting of such sexual misconduct
55. 944.35(3) relating to inflicting cruel or inhuman treatment on an inmate
resulting in great bodily harm
56. 944.40
relating to escape
57. 944.46
relating to harboring, concealing, or aiding an escaped prisoner
58. 944.47
relating to introduction of contraband into a correctional facility
59. 985.701
relating to sexual misconduct in juvenile justice programs
60. 985.711
relating to contraband introduced into detention facilities
Comment:________________________________________________________________________________
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_________________________________________________________________________________________
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