Doea Form 231 - Background Screening - Affidavit Of Good Moral Character

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BACKGROUND SCREENING
Affidavit of Good Moral Character
AUTHORITY: This form is required of all employees, volunteers, and direct service providers
to comply with the attestation requirements set forth in section 435.02(2), Florida Statutes.
 The term “employee” as used herein refers collectively to all persons required by law to undergo
background screening. This includes, but is not limited to, a direct service provider which means a person
at least 18 years of age who, pursuant to a program to provide services to the elderly, has direct face-to-
face contact with a client while providing services, or has access to the client’s living area, funds, or
personal property. A direct service provider also includes coordinators, managers, and supervisors of
residential facilities; and volunteers.
 The term “employer” means any person or entity required by law to conduct background screening,
including but not limited to, the Department of Elder Affairs, Area Agencies on Aging, Aging Resource
Centers, Aging and Disability Resource Centers, Lead Agencies, Long-Term Care Ombudsman Program,
Service Providers, Diversion Providers, and any other person or entity which hires employees, direct
service providers, or has volunteers in service.
 Each employee must attest, subject to penalty of perjury, to meeting the requirements for qualifying for
employment pursuant to background screening standards set forth in Chapter 435 and section 430.0402,
Florida Statutes, and must agree to inform the employer immediately if arrested for any of the
disqualifying offenses listed in those statutes while employed by the employer.
EMPLOYER: THIS COMPLETED FORM MUST BE FORWARDED TO THE DEPARTMENT OF ELDER AFFAIRS
WITH THE COMPLETED APPOINTMENT FORM IN ORDER FOR BACKGROUND SCREENING TO PROCEED.
A copy of this form should be maintained in the employee’s personnel file.
STEP ONE:
Complete employee and employer contact information.
_________________________________________
_______________________________________
Employee Name
Employee Date of Birth
_________________________________________
_______________________________________
Employer Name
Employer Contact Person
______________________________________________________________________________________
Employer Address
City
Zip code
_(_____)_________________________
__________________________________________________
Employer Telephone Number
Employer Email
DOEA Form 231, Affidavit of Good Moral Character, Effective 8-1-11
Section 435.02(2), F.S.
*Previous versions of this form will not be accepted*
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