DJJ Form IG/BSU-001 "Request for Background Screening for DJJ State Employment & Volunteers" - Florida

Form IG/BSU-001 or the "Request For Background Screening For Djj State Employment & Volunteers" is a form issued by the Florida Department of Juvenile Justice.

Download a PDF version of the Form IG/BSU-001 down below or find it on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form IG/BSU-001 "Request for Background Screening for DJJ State Employment & Volunteers" - Florida

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IG/BSU-001
Revised 04/18
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE - OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
REQUEST FOR BACKGROUND SCREENING
DJJ STATE EMPLOYMENT & VOLUNTEERS
FOR
Detention
Residential
Probation
Prevention
Administration
Other______________________
Check this box if the applicant is or was
a Florida law enforcement officer or certified officer with the Department of Corrections
A. TO BE COMPLETED BY APPLICANT/VOLUNTEER/INTERN
Last Name
First Name
Full Middle Name
Maiden/A
lias
Position Applied for
Caretaker
Special Trust
Not Special Trust
Driver’s License #:
Social Security #:
Race/Sex:
DOB:
Date Submitted:
B. TO BE COMPLETED BY REQUESTOR
Requestor’s Name (Contact Person)
Telephone Number & Ext. #
Fax Telephone Number
Office/Facility/Program Name and Mail Address
E-mail Address
I hereby authorize the Department of Juvenile Justice (DJJ) to check any records pertaining to my criminal history, driver’s license history, and juvenile
criminal history pursuant to Sections 39.001 and Chapters 435, 984, and 985, Florida Statutes. I further authorize any law enforcement agency to release to
DJJ information regarding convictions and dispositions under Florida Statutes or statutes of other jurisdictions. I understand that as a criminal justice agency,
DJJ has access to all criminal records, even those that have been sealed or expunged. This consent applies to any and all future screenings conducted by DJJ.
I understand that my fingerprints will be submitted for a criminal records check to the Florida Department of Law Enforcement (FDLE) and the Federal
Bureau of Investigations (FBI) and that once submitted, my fingerprints will be retained by FDLE while I am employed at DJJ and if arrested, the arrest will
be reported directly to DJJ by FDLE.
Applicant’s Signature
People First ID
Date
C. FOR BSU PERSONNEL USE ONLY
Note: The applicant’s fingerprints are submitted to the Florida and National Crime Information Centers (FCIC/NCIC).Criminal history reports are the
result of fingerprint analysis conducted by the Florida Department of Law Enforcement and Federal Bureau of Investigations.
Eligible
Ineligible/Not Eligible
Identified/Non-Caretaker Only
(Applicant has a disqualifying offense, but will
(Applicant has a disqualifying offense. Exemption is needed to
not work in a position of special trust or
work or serve in a position of special trust or responsibility.)
responsibility.)
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
*The Criminal History Record provided is exempt from chapter 119 and should not be disclosed or disseminated
Yes
No
Criminal Record*:
(Attached)
TCN#:
Yes
No
Subject of Reportable Incident:
(Attached)
Automated Training Management
Yes
System:
(Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date:
Clear Form
Save As..
Print
IG/BSU-001
Revised 04/18
CONFIDENTIAL
DEPARTMENT OF JUVENILE JUSTICE - OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
REQUEST FOR BACKGROUND SCREENING
DJJ STATE EMPLOYMENT & VOLUNTEERS
FOR
Detention
Residential
Probation
Prevention
Administration
Other______________________
Check this box if the applicant is or was
a Florida law enforcement officer or certified officer with the Department of Corrections
A. TO BE COMPLETED BY APPLICANT/VOLUNTEER/INTERN
Last Name
First Name
Full Middle Name
Maiden/A
lias
Position Applied for
Caretaker
Special Trust
Not Special Trust
Driver’s License #:
Social Security #:
Race/Sex:
DOB:
Date Submitted:
B. TO BE COMPLETED BY REQUESTOR
Requestor’s Name (Contact Person)
Telephone Number & Ext. #
Fax Telephone Number
Office/Facility/Program Name and Mail Address
E-mail Address
I hereby authorize the Department of Juvenile Justice (DJJ) to check any records pertaining to my criminal history, driver’s license history, and juvenile
criminal history pursuant to Sections 39.001 and Chapters 435, 984, and 985, Florida Statutes. I further authorize any law enforcement agency to release to
DJJ information regarding convictions and dispositions under Florida Statutes or statutes of other jurisdictions. I understand that as a criminal justice agency,
DJJ has access to all criminal records, even those that have been sealed or expunged. This consent applies to any and all future screenings conducted by DJJ.
I understand that my fingerprints will be submitted for a criminal records check to the Florida Department of Law Enforcement (FDLE) and the Federal
Bureau of Investigations (FBI) and that once submitted, my fingerprints will be retained by FDLE while I am employed at DJJ and if arrested, the arrest will
be reported directly to DJJ by FDLE.
Applicant’s Signature
People First ID
Date
C. FOR BSU PERSONNEL USE ONLY
Note: The applicant’s fingerprints are submitted to the Florida and National Crime Information Centers (FCIC/NCIC).Criminal history reports are the
result of fingerprint analysis conducted by the Florida Department of Law Enforcement and Federal Bureau of Investigations.
Eligible
Ineligible/Not Eligible
Identified/Non-Caretaker Only
(Applicant has a disqualifying offense, but will
(Applicant has a disqualifying offense. Exemption is needed to
not work in a position of special trust or
work or serve in a position of special trust or responsibility.)
responsibility.)
Apply for EXEMPTION
Applicant CAN
Applicant CANNOT
*The Criminal History Record provided is exempt from chapter 119 and should not be disclosed or disseminated
Yes
No
Criminal Record*:
(Attached)
TCN#:
Yes
No
Subject of Reportable Incident:
(Attached)
Automated Training Management
Yes
System:
(Attached)
No
N/A
COMMENTS:
Signature of Screener:
Date:
Signature of Reviewer:
Date:
Clear Form
Save As..
Print
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