DJJ Form IG/BSU-004 "Request for Five-Year Check (Rescreening) for DJJ State Employees & Volunteers" - Florida

Form IG/BSU-004 or the "Request For Five-year Check (rescreening) For Djj State Employees & Volunteers" is a form issued by the Florida Department of Juvenile Justice.

The form was last revised in April 1, 2018 and is available for digital filing. Download an up-to-date Form IG/BSU-004 in PDF-format down below or look it up on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form IG/BSU-004 "Request for Five-Year Check (Rescreening) for DJJ State Employees & Volunteers" - Florida

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IG/BSU-004
Revised 04/18
CONFIDENTIAL
-
DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
(RESCREENING)
REQUEST FOR FIVE-YEAR CHECK
FOR
DJJ STATE EMPLOYEES & VOLUNTEERS
Other ___________________
Detention
Residential
Probation
Prevention
Administration
A.
TO BE COMPLETED BY EMPLOYEE/VOLUNTEER
Last Name
First Name
Full Middle Name
Maiden/Alias
_____________________
Race/Sex
DOB
People First ID
Current Job Title
Facility/Office
City
Driver’s License Number & State
Social Security Number
Agency Hire Date
(Must provide to calculate next Rescreen due date.)
B.
TO BE COMPLETED BY REQUESTOR
DATE SUBMITTED:
____________________
Requestor’s Name (Contact Person)
Telephone Number & Ext #
Fax Telephone Number
Office/Facility/Program Name and Mailing Address
E-Mail Address
Date of Last 5-Year Rescreen
RATING SECTION – TO BE COMPLETED BY THE BACKGROUND SCREENING UNIT
C.
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
(Applicant has a disqualifying offense.
(Applicant has a disqualifying offense, but will not
Exemption is needed to continue in a
work in a position of special trust or
position of special trust or responsibility.)
responsibility.)
Judicial Inquiry System:
Yes (Attached)
No
Criminal Record Attached*: _____ Yes
_____No
TCN#:
________________________________________
*Criminal history information provided is exempt from chapter 119 and should not be disseminated further.
Apply for
Applicant
Applicant CAN
EXEMPTION
CANNOT
The next 5-Year Rescreen must be completed by:
______________________
Comments:
Signature of Screener
Date
Signature of Reviewer
Date
Clear Form
Save As..
Print
IG/BSU-004
Revised 04/18
CONFIDENTIAL
-
DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF THE INSPECTOR GENERAL
BACKGROUND SCREENING UNIT
(RESCREENING)
REQUEST FOR FIVE-YEAR CHECK
FOR
DJJ STATE EMPLOYEES & VOLUNTEERS
Other ___________________
Detention
Residential
Probation
Prevention
Administration
A.
TO BE COMPLETED BY EMPLOYEE/VOLUNTEER
Last Name
First Name
Full Middle Name
Maiden/Alias
_____________________
Race/Sex
DOB
People First ID
Current Job Title
Facility/Office
City
Driver’s License Number & State
Social Security Number
Agency Hire Date
(Must provide to calculate next Rescreen due date.)
B.
TO BE COMPLETED BY REQUESTOR
DATE SUBMITTED:
____________________
Requestor’s Name (Contact Person)
Telephone Number & Ext #
Fax Telephone Number
Office/Facility/Program Name and Mailing Address
E-Mail Address
Date of Last 5-Year Rescreen
RATING SECTION – TO BE COMPLETED BY THE BACKGROUND SCREENING UNIT
C.
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
(Applicant has a disqualifying offense.
(Applicant has a disqualifying offense, but will not
Exemption is needed to continue in a
work in a position of special trust or
position of special trust or responsibility.)
responsibility.)
Judicial Inquiry System:
Yes (Attached)
No
Criminal Record Attached*: _____ Yes
_____No
TCN#:
________________________________________
*Criminal history information provided is exempt from chapter 119 and should not be disseminated further.
Apply for
Applicant
Applicant CAN
EXEMPTION
CANNOT
The next 5-Year Rescreen must be completed by:
______________________
Comments:
Signature of Screener
Date
Signature of Reviewer
Date
Clear Form
Save As..
Print
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