Attestation of Good Moral Character

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ATTESTATION OF GOOD MORAL CHARACTER

Employee/Contractor Name:

Health Care Provider/Employer Name:

Address of Health Care Provider:

By signing this form, I affirm and attest that I meet the Moral Character requirements for employment as required pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.

I have not been arrested with disposition pending or found guilty of regardless of adjudication or entered a plea of nolo contendere (no contest) 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 the Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed below.

Criminal offenses found in section 435.04, F.S.

(a) Section 39.205, relating to the failure to report child abuse, abandonment, or neglect.

(b) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.

(c) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.

(d) Section 414.39, relating to fraud, if the offense was a felony.

(e) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.

(f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.

(g) Section 782.04, relating to murder.

(h) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.

(i) Section 782.071, relating to vehicular homicide.

(j) Section 782.09, relating to killing of an unborn child by injury to the mother.

(k) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.

(l) Section 784.011, relating to assault, if the victim of the offense was a minor.

(m) Section 784.021, relating to aggravated assault.

(n) Section 784.03, relating to battery, if the victim of the offense was a minor.

(o) Section 784.045, relating to aggravated battery.

(p) Section 784.075, relating to battery on staff of a detention or commitment facility or on a juvenile probation officer.

(q) Section 787.01, relating to kidnapping.

(r) Section 787.02, relating to false imprisonment.

(s) Section 787.025, relating to luring or enticing a child.

(t) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody.

(u) Section 787.04(3), relating 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.

(v) Section 787.06, relating to human trafficking.

(w) Section 787.07, relating to human smuggling.

(x) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.

(y) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.

(z) Section 794.011, relating to sexual battery.

(aa) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.

(bb) Section 794.05, relating to unlawful sexual activity with certain minors.

(cc) Section 794.08, relating to female genital mutilation.

(dd) Chapter 796, relating to prostitution.

(ee) Section 798.02, relating to lewd and lascivious behavior.

(ff) Chapter 800, relating to lewdness and indecent exposure.

(gg) Section 806.01, relating to arson.

(hh) Section 810.02, relating to burglary.

(ii) Section 810.14, relating to voyeurism, if the offense is a felony.

(jj) Section 810.145, relating to video voyeurism, if the offense is a felony.

(kk) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.

(ll) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.

(mm) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(nn) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

(ggg) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.

(oo) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(pp) Section 826.04, relating to incest.

(qq) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.

(rr) Section 827.04, relating to contributing to the delinquency or dependency of a child.

(ss) Former s. 827.07, relating to negligent treatment of children.

(tt) Section 827.071, relating to sexual performance by a child.

(uu) Section 831.31, relating to the unlawful sale, manufacture, alteration, delivery, uttering, or possession of counterfeit-resistant prescription blanks for controlled substances.

(vv) Section 836.10, relating to written or electronic threats to kill, do bodily injury, or conduct a mass shooting or an act of terrorism.

(ww) Section 843.01, relating to resisting arrest with violence.

(xx) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(yy) Section 843.12, relating to aiding in an escape.

(zz) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.

(aaa) Chapter 847, relating to obscene literature.

(bbb) Section 859.01, relating to poisoning food or water.

(ccc) Section 873.01, relating to the prohibition on the purchase or sale of human organs and tissue.

(ddd) Section 874.05, relating to encouraging or recruiting another to join a criminal gang.

(eee) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.

(fff) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

(hhh) Section 944.40, relating to escape.

(iii) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.

435.04(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or another jurisdiction.

Section 393.0674(2), felony offenses for the release or use of information from juvenile records of the Agency for Persons with Disabilities for any purpose other than screening for employment.

Criminal Offenses listed in section 393.0655 (5), F.S.

(a) Any authorizing statutes, if the offense was a felony.

(b) This chapter, if the offense was a felony.

(d) Section 409.9201, relating to Medicaid fraud.

(e) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photoptical systems.

(f) Section 817.234, relating to false and fraudulent insurance claims.

(g) Section 817.505, relating to patient brokering.

(h) Section 817.568, relating to criminal use of personal identification information.

(i) Section 817.60, relating to obtaining a credit card through fraudulent means.

(j) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.

(k) Section 831.01, relating to forgery.

(l) Section 831.02, relating to uttering forged instruments.

(m) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.

(n) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please initial each statement.

I affirm that I have not been designated as a sexual predator pursuant to s. 775.21; a career offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354.

I understand that, while employed or volunteering in any position that requires an APD background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest, any notice of possible criminal prosecution including any violation or infraction mandating a court appearance. Reporting must be done immediately if during normal working hours or immediately the next business day if after normal working hours.

I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged.

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED

I attest that I have read the above carefully and state that my attestation here is true and correct and that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements to the background screening standards set forth in Chapter 435 and Section 393.0655.

Signature

Date

Or

My record contains one or more of the applicable disqualifying acts or offenses listed above.

Signature

Date

Note: If you have previously been granted an APD exemption for this disqualifying offense, a copy of the APD exemption letter must be attached.

Or

I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of my licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes

Signature

Date

Attestation of Good Moral Character