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Important Information for all Exemption ApplicantsYou must hold a valid, active license to be eligible for an exemption.If you do not have a license you must apply for an exemption with the Agency for Health CareAdministration. If you are in the process of applying for a license you do not need to fill out the exemptionapplication separately, you may include a note in your application that you will need an exemption and wewill handle it as we process your application for licensure.An exemption cannot be issued to any person who is a:1. Sexual predator as designated pursuant to s. 775.21;2. Career offender pursuant to s. 775.261 ; or3. Sexual offender pursuantto s. 943.0435, unless the requirement to register as a sexual offender has.been removed pursuant to s. 943.04354If you have not previously reported these offenses to the Board your file will be forwarded to ourConsumer Services office and your exemption application will be placed on hold. All investigations areconfidential and staff will not be able to provide you with any further information until you are contacted by aninvestigator. If you need to report the offense, submit a detailed letter regarding the offense(s) or complete acomplaint form with the Consumer Services Unit and mail to: 4052 Bald Cypress Way, Bin C-75, Tallahassee,FL 32399.Please make copies of all documents for your records.Section 435.07(3),F.S states, “ the employee must demonstrate by clear and convincing evidence thatthe employee should not be disqualified from employment. Employees seeking an exemption have theburden of setting forth sufficient evidence of rehabilitation, including, but not limited to, the circumstancessurrounding the criminal incident for which an exemption is sought, the time period that has elapsed since theincident, the nature of the harm caused to the victim, and the history of the employee since the incident, or anyother evidence or circumstances indicating that the employee will not present a danger if continuedemployment is allowed ”.All licensees with any offense listed in Section 408.809 Florida Statutes must also apply for an exemption.If you have a Felony Disqualifying Offense, and you have not completed or been lawfully released fromconfinement, supervision, or non-monetary conditions imposed by the court for the disqualifying felony in thelast 3 years, you will not qualify for an exemption. All disqualifying offenses (felonies and misdemeanors)that have adjudication withheld will be handled the same as a conviction for the purposes of this exemptionrequest.In order to qualify for an exemption, you must have paid any amount for any fee, fine, fund, lien, civiljudgement, application, cost of prosecution, trust, or restitution as part of the judgement and sentence forany disqaulfying felony or misdemeanor in full.All requested information must be submitted before a determination can be made.The appropriate Boardwithin the Department of Health will make notification when a decision related to the request is made.Mail the application and any required documents to:Florida Board of Nursing4052 Bald Cypress Way, BIN C-02Tallahassee, Florida 32399-3252Revised 10/14Page 1
Exemption ChecklistIT IS IMPORTANT TO PROVIDE ALL THE INFORMATION BELOW AND CHECK EACH ITEMAS YOU OBTAIN IT Agency for Health Care Administration (AHCA) Level II Screening- Licensees who have completeda Level II screening with AHCA within the last three (3) months are not required to complete Livescanfingerprints. Please note: In the event we cannot verify your screening with AHCA, you will berequired to complete the Live Scan requirement.ORLivescan- The Department of Health only accepts electronic fingerprinting offered by Livescanservice providers that are approved by the Florida Department of Law Enforcement.For a list of approved Livescan vendors and Frequently Asked Questions please visit our website ders.htmlOur ORI number is EDOH4420Z.Self-Explanation- You must submit a letter in your own words describing in detail the circumstancessurrounding each offense; including date, city and state, charges and final results. This letter must includehow you demonstrate by clear and convincing evidence that you should not be disqualified from employment.A description of any violation of probation must be included in this letter.Court Disposition(s)- You must submit documentation from the county Clerk of Courts in thejurisdiction (state/county) in which the offense(s) occurred, including disposition/final results. (Forjuvenile offenses ONLY- Please include records indicating adjudication and whether the case(s) havebeen sealed or expunged.)Arrest Report(s)- You must submit a copy of the arrest report for each offense.You may obtain acopy of this report from the arresting agency (Police or Sheriff's Department).Probation/Parole or PTI Letter(s)- You must submit proof of completion of all court orderedprobation/parole or PTI (Pre-trial intervention). This documentation must be issued by the probationoffice and must include the start date and termination date of your probation.Recommendation Letters- You must submit three (3) current (written within the last year) lettersof professional recommendation on official letterhead from employers, nursing program administrators,nursing instructors, health professionals, professional counselors, support group sponsors, parole orprobation officers, or other individuals in positions of authority who are familiar with your past and presentcharacter.Proof of Rehabilitation- You must submit proof of rehabilitation which may include lettersfrom employer’s records of successful participation in a rehabilitation program(s), further educationor training, special awards or recognition, or documentation that indicates you are not a danger to thesafety or well being of others.Revised 10/14Page 2
Florida Board of Nursing4052 Bald Cypress Way, Bin C-02Tallahassee, FL 32399Phone: (850) 245-4125Fax: (850) 617-6460Exemption ApplicationWebsite: www.floridasnursing.govEmail: Mqa.NursingAppstatus@flhealth.govPlease complete this application inits entirety prior to printing.You must hold a active Florida license to qualify for an exemption.Profession Type: (Check one only)Licensed Practical Nurse (LPN) 1702Registered Nurse (RN) 1701Advanced Practice Registered Nurse (APRN) 1711Background Screening: (Check one only)I have completed a Level II background screening with the Agency for Health Care Administration (AHCA)in the last three (3) months.I have NOT been subjected to a Level II background screening. (Livescan required)Social Security Number:Florida License Number:Name:FirstLast/SurnameMiddleMailing Address:Apt. No.Street/P.O. BoxStateZipCountryCityHome/Cell Telephone (Input without dashes)Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website.)StreetStateSex:Apt./Suite No.CountryZipCityWork/Cell Telephone (Input without dashes)Date of Birth:Race:MM/DD/YYYYEmail Address:I am formally requesting the Department of Health, in accordance with the provision of Chapter 435, provide me with an exemptionreview. I understand that I must provide clear and convincing evidence to support a reasonable belief that I am of good moralcharacter and that I pose no danger to the health or safety of patients.I also understand that the decision of the Department of Health regarding this exemption may be contested through a hearingunder the provisions of Chapter 120,F.S.I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retentionprivacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the FederalBureau of Investigation. (Found in Forms Section of this application).Applicant's SignatureDateThis field cannot be typed. You must print out the application and sign it.Revised 10/14Page 3MM/DD/YYYY
Electronic FingerprintingTake this form with you to the Livescan service provider. Please check the service provider'srequirements to see if you need to bring any additional items. Background screening results are obtained from the Florida Department of Law Enforcement andthe Federal Bureau of Investigation by submitting to a fingerprint scan using the Livescan method; You can find a Livescan service provider at: http://www.floridahealth.gov/mqa/background.html; Livescan screenings done by a Florida Police or Sheriff's Department require that you login to theFDLE Civil Applicant Payment System (CAPS) at https://caps.fdle.state.fl.us and pay a fee beforeresults will be released to our office. Out of State/Country Livescan directions are included in the electronic fingerprinting section of thisapplication. If you do not provide the correct Originating Agency Identification (ORI) number to the Livescanservice provider the Board office will not receive your background screening results; You must provide accurate demographic information to the Livescan service provider at thetime your fingerprints are taken, including your Social Security number (SSN); The ORI number for the Board of Nursing is: EDOH4420Z. Typically background screening results submitted through a Livescan service provider arereceived by the Board within 24-72 hours of being processed. If you obtain your Livescan from a service provider who does not capture your photo you may berequired to be reprinted by another agency in the future.Name:Aliases:Place of Birth:Date of Birth:(MM/DD/YYYY)Social Security Number:Race:Citizenship:(W-White/Latino(a); B-Black; A-Asian; NA-Native American; U-Unknown)Sex:Height:Weight:(M Male; F Female)Eye Color:Hair Color:Apt. Number:Address:City:State:Zip Code:Transaction Control Number (TCN#):(This will be provided to you by the Live Scan Vendor.)You will need to keep this form for your records. Do not send this form to the Board Office.Revised 10/14Page 4
FLORIDA DEPARTMENT OF LAW ENFORCEMENTNOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILLBECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSENOTICE OF: SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES, RETENTION OF FINGERPRINTS, PRIVACY POLICY, AND RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORDThis notice is to inform you that when you submit a set of fingerprints to the Florida Department of LawEnforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal historyrecords that may pertain to you, the results of that search will be returned to the Care Provider BackgroundScreening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state andnational criminal history record that may pertain to you to the Specified Agency or Agencies from which you areseeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to theNational Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency"means the Department of Health, the Department of Children and Family Services, the Division of VocationalRehabilitation within the Department of Education, the Agency for Health Care Administration, the Departmentof Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when theseagencies are conducting state and national criminal history background screening on persons who providecare for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLEand the Clearinghouse will be notified if FDLE receives Florida arrest information on you.Your Social Security Number (SSN) is needed to keep records accurate because other people mayhave the same name and birth date. Disclosure of your SSN is imperative for the performance of theClearinghouse agencies' duties in distinguishing your identity from that of other persons whoseidentification information may be the same as or similar to yours.Licensing and employing agencies are allowed to release a copy of the state and national criminal recordinformation to a person who requests a copy of his or her own record if the identification of the record was basedon submission of the person's fingerprints. Therefore, if you wish to review your record, you may request thatthe agency that is screening the record provide you with a copy. After you have reviewed the criminal historyrecord, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s.943.056, F.S., and Rule 11C-8.001, F.A.C. If national information is believed to be in error, the FBI should becontacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directlyfrom the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination asto the validity of your challenge before a final decision is made about your status as an employee, volunteer,contractor, or subcontractor.Until the criminal history background check is completed, you may be denied unsupervised access to children,the elderly, or persons with disabilities.The FBI's Privacy Statement follows on a separate page and contains additional information.Revised 10/14Page 5
PRIVACY STATEMENTUS Department of Justice, Federal Bureau of InvestigationCriminal Justice Information Services DivisionAuthority: The FBI's acquisition, preservation and exchange of information requested by this form is generallyauthorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities includenumerous Federal statutes, hundreds of State statutes pursuant to Pub.L.92-544, Presidential executive orders,regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examplesinclude, but are not limited to: 5 U.S.C. 9101; Pub.L.94-29; Pub.L.101-604; and Executive Orders 10450 and12968. Providing the requested information is voluntary; however, failure to furnish the information may affecttimely completion of approval of your application.Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other peoplemay have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), therequesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutoryor other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asksFederal Agencies to use this number to help identify individuals in agency records.Principal Purpose: Certain determinations, such as employment, security, licensing and adoption, may bepredicated on fingerprint based checks. Your fingerprints and other information contained on (and along with) thisform may be submitted to the requesting agency, the agency conducting the application investigation, and/or FBIfor the purpose of comparing the submitted information to available records in order to identify other informationthat may be pertinent to the application. During the processing of this application, and for as long hereafter as mybe relevant to the activity for which this application is being submitted, the FBI( may disclose any potentiallypertinent information to the requesting agency and/or to the agency conducting the investigation. The FBI mayalso retain the submitted information in the FBI's permanent collection of fingerprints and related information,where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature ofyour application, the requesting agency and/or the agency conducting the application investigation may also retainthe fingerprints and other submitted information for other authorized purposes of such agency(ies).Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent,and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5USC 552a(b)) and all applicable routine uses as many be published at any time in the Federal Register, includingthe routine uses for the FBI Fingerprint Identification Records System (Justice, FBI-009) and the FBI's BlanketRoutine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to, disclosures to: appropriategovernmental authorities responsible for civil or criminal law enforcement counterintelligence, national security orpublic safety matters to which the information may be relevant; to State and local governmental agencies andnongovernmental entities for application processing as authorized by Federal and State legislation, executiveorder, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorizedby law , treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processingthe application, they may have additional routine uses.Additional Information: The requesting agency and/or the agency conducting the application investigation willprovide you additional information pertinent to the specific circumstances of this application, which may includeidentification of other authorities, purposes, uses, and consequences of not providing requested information. Inaddition, any such agency in the Federal Executive Branch has also published notice.Revised 10/14Page 6
435.04 Level 2 screening standards—(1)(a) All employees required by law to be screened pursuant to this section must undergo security backgroundinvestigations as a condition of employment and continued employment which includes, but need not be limitedto, fingerprinting for statewide criminal history records checks through the Department of Law Enforcement, andnational criminal history records checks through the Federal Bureau of Investigation, and may include localcriminal records checks through local law enforcement agencies.(b) Fingerprints submitted pursuant to this section on or after July 1, 2012, must be submitted electronically to theDepartment of Law Enforcement.(c) An agency may contract with one or more vendors to perform all or part of the electronic fingerprinting pursuant tothis section. Such contracts must ensure that the owners and personnel of the vendor performing the electronicfingerprinting are qualified and will ensure the integrity and security of all personal information.(d) An agency may require by rule that fingerprints submitted pursuant to this section must be submitted electronically tothe Department of Law Enforcement on a date earlier than July 1, 2012.(2)The security background investigations under this section must ensure that no persons subject to the provisions ofthis section have been arrested for and are awaiting final disposition of, have been found guilty of, regardless ofadjudication, or entered a plea of nolo contendere or guilty to, or have been adjudicated delinquent and the recordhas not been sealed or expunged for, any offense prohibited under any of the following provisions of state law orsimilar law of another jurisdiction:(a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of suchsexual misconduct.(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexualmisconduct.(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.(d) Section 777.04, relating to attempts, solicitation, and conspirarcy to commit an offense listed in this subsection.(e) Section 782.04 , relating to murder.(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, oraggravated manslaughter of a child.(g) Section 782.071, relating to vehicular
Probation/Parole or PTI Letter(s) . from employer’s records of successful participation in a rehabilitation program(s), further education probation/parole or PTI (Pre-trial intervention). . Licensed Practical Nurse (LPN
