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

Form IG/BSU-005 is a Florida Department of Juvenile Justice form also known as the "Request For Clearinghouse Screening For Provider Volunteers". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a PDF version of the Form IG/BSU-005 down below or find it on Florida Department of Juvenile Justice Forms website.

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

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IG/BSU-005
Revised 4/18
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE - OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
REQUEST FOR CLEARINGHOUSE SCREENING
INITIAL SCREENING, AGENCY REVIEW AND RESUBMISSIONS
VOLUNTEERS
FOR PROVIDER
Detention
Residential
Probation
Prevention
Research
Other______________________
Check this box if applicant is or was
a Florida law enforcement officer or a 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 Telephone Number
Email Address: ____________________________________________
Office/Facility/Program Name
C. FOR BSU PERSONNEL USE ONLY
“Public Rap Sheet”
button to view the applicant’s Florida criminal history.
Providers must check the Clearinghouse Portal for results and click the
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
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 (Attached)
No
Subject of DJJ Reportable
Incident:
Yes (Attached)
No
Automated Training
Management System:
Yes (Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date:
Clear Form
Save As..
Print
IG/BSU-005
Revised 4/18
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE - OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
REQUEST FOR CLEARINGHOUSE SCREENING
INITIAL SCREENING, AGENCY REVIEW AND RESUBMISSIONS
VOLUNTEERS
FOR PROVIDER
Detention
Residential
Probation
Prevention
Research
Other______________________
Check this box if applicant is or was
a Florida law enforcement officer or a 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 Telephone Number
Email Address: ____________________________________________
Office/Facility/Program Name
C. FOR BSU PERSONNEL USE ONLY
“Public Rap Sheet”
button to view the applicant’s Florida criminal history.
Providers must check the Clearinghouse Portal for results and click the
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
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 (Attached)
No
Subject of DJJ Reportable
Incident:
Yes (Attached)
No
Automated Training
Management System:
Yes (Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date:
Clear Form
Save As..
Print
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