AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

Jurisdiction: Country: United States | Province/State: Florida

What is an AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements?

This form records your compliance with Florida’s health care background screening rules. It confirms, in writing, that you completed a Level 2 background check. It also confirms that you verified eligibility through the AHCA Background Screening Clearinghouse.

Think of it as the hiring and compliance receipt. It captures who was screened, why they were screened, and when. It also documents how you verified eligibility and whether you rely on prior results. You keep it in the personnel or contractor file. You show it to surveyors or auditors when asked. You do not submit it unless requested.

Who typically uses this form?

Licensed health care providers in Florida use it. That includes facilities and agencies that AHCA licenses. It also includes entities that must screen owners, administrators, managers, employees, and contractors. HR leaders, compliance officers, provider owners, administrators, and credentialing staff handle it. Vendor managers use it for contract staff with patient access.

You need this form when you hire or contract with anyone who needs a Level 2 screening. You also use it when you rely on prior Clearinghouse eligibility. The form documents the basis for allowing the person to work. It ties the person to your organization and your verification steps. It also supports your internal controls during inspections.

Typical usage scenarios include

• You onboard a nurse, aide, therapist, or technician. You verify Clearinghouse eligibility and attest to compliance.
• You bring in a contractor, such as a staffing agency nurse, who will have patient contact. You document eligibility before the first shift.
• You reassign a back-office employee into a patient-facing role. You confirm the person’s eligibility and update the attestation.
• You rehire someone after a short break. You verify the prior screening still qualifies. You document the break-in-service analysis.
• You complete a five-year rescreen. You attest that the new screening shows eligibility.
• You onboard a new owner or manager who must be screened. You document their eligibility and your review of the Clearinghouse.

The form supports your core duty: do not allow disqualified individuals to work in covered roles. It also shows that you monitor five-year rescreens and arrest notifications. It keeps your compliance story clear and complete.

When Would You Use an AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements?

You use this form whenever you make a decision to place a person in a screened role. This includes employees, contractors, volunteers, students, and owners who require screening. Complete it before the person starts any covered work. Do not wait until after orientation or training. You need it ready for review on day one.

• Use it at initial hire. For example, you hire a home health aide. You initiate a Clearinghouse screening, capture fingerprints, and verify eligibility. You complete the attestation and keep it in the personnel file.
• Use it when you rely on a prior Clearinghouse result. For example, a CNA leaves a nursing home and joins your clinic within 90 days. You check the Clearinghouse profile and confirm eligibility and retained prints. You add the employee to your roster in the Clearinghouse. You complete the attestation to show you relied on the existing result.
• Use it when you use contractor staff. For example, an ALF contracts with a therapy company. The therapists will see residents on-site. You get proof of each therapist’s Clearinghouse eligibility. You complete an attestation for each therapist or document the vendor’s attestation. You keep the documentation in your vendor file.
• Use it when the job duties change. For example, you promote a scheduler to a role with patient access. You verify eligibility and complete an attestation tied to the new role. You place the attestation in the personnel file.
• Use it when a break in service may trigger rescreening. For example, a nurse returns after 100 days away from any screened job. You complete a new screening and a new attestation.
• Use it for five-year rescreens. For example, a technician reaches the five-year mark from their last fingerprint date. You submit new prints, confirm the new eligibility, and complete a fresh attestation.
• Use it when an exemption from disqualification is approved. For example, a medication aide has a disqualifying offense but obtains an exemption. You attach the exemption approval and complete the attestation.

Typical users

• Provider owners
• Administrators
• HR managers
• Credentialing staff
• Compliance officers
• Vendor managers

If you control onboarding, you will use this form. If you control contractors or students, you will use this form.

Legal Characteristics of the AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

This form is a formal statement that you followed state rules. It is signed under penalty for false statements. It is part of your licensure compliance record. Inspectors and auditors will expect to see it on-site. It is evidence that you verified eligibility at the right time and in the right way.

It is legally binding because it memorializes required screening steps. You declare that the person completed a Level 2 fingerprint-based check. You declare that you reviewed the Clearinghouse record and eligibility. You also declare that you will maintain arrest notification monitoring. You accept responsibility for removing the person from duty if eligibility changes.

Enforceability comes from your licensure conditions. The background screening rules are a condition of licensure. The attestation shows you met those conditions. If you misstate facts or skip steps, you risk sanctions. That can include fines, corrective action, or denial of renewal. It can also include action against owners or managers.

General legal considerations:

• Timing matters. Complete the screening and attestation before any covered duty.
• Identity must match. Names, aliases, date of birth, and identifiers must be accurate.
• Eligibility must be current. Check the Clearinghouse each time you hire or add duties.
• Rescreens are required. Track the five-year rescreen dates for each person.
• Arrest notifications must be active. Keep the person enrolled for new arrest alerts.
• Breaks in service affect eligibility. Long gaps can require new screening.
• Exemptions must be documented. Keep the official approval in the file.
• Contractors are your responsibility. Do not rely on a vendor’s promise without proof.
• Confidentiality applies. Limit access to screening records to those who need it.

Treat the attestation as a compliance checkpoint. It is your defense during inspections. It is a single page that proves you took the right steps.

How to Fill Out an AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

Use this step-by-step guide. Keep the form clean and complete. Use black ink or a fillable PDF. Do not leave required fields blank. If a field does not apply, write “N/A.”

Step 1: Identify the provider or employer

• Enter the legal name of your organization. Use the exact name on your license.
• Enter your AHCA license number, if you have one. Use the main license number.
• Provide your physical address. Include city, state, and ZIP.
• Add a contact person. List a phone number and email address.
• If you are a contractor agency, list your company name here.

Tip: Consistency helps. Match your name and license number to your posted license.

Step 2: Identify the individual being screened

• Enter the person’s full legal name. Use first, middle, and last name.
• List any other names used. Include prior surnames and aliases.
• Enter date of birth. Ensure the date matches the Clearinghouse entry.
• Enter the last four digits of the SSN or Clearinghouse ID, if requested.
• State the job title or role. Use simple titles like “CNA,” “HHA,” or “RN.”
• Indicate employment type. Note employee, contractor, volunteer, or student.
• If the person is an owner or manager, state that clearly.

Tip: The name must match the fingerprints and Clearinghouse profile.

Step 3: Describe the screening event

• Select the reason for screening. Choose initial hire, rescreen, or change in role.
• Enter the date fingerprints were submitted. Use the date on the receipt.
• Enter the Clearinghouse screening identifier, if available. This helps audits.
• Note if photographs and retained prints are in place. Most new screens include both.

Tip: Keep the fingerprint submission receipt in the file behind the attestation.

Step 4: Record the eligibility determination

• Check the status shown in the Clearinghouse. Mark “Eligible” if shown.
• If the status is “Not Eligible,” stop. Do not allow work.
• If “Pending,” wait for the final result. Do not allow unsupervised work.
• Enter the eligibility date. Use the date on the Clearinghouse record.
• Confirm arrest notification enrollment. This is part of ongoing monitoring.

Tip: Print or save the Clearinghouse eligibility page. Attach it behind the attestation.

Step 5: Address reliance on prior results (if applicable)

• If you rely on a prior Clearinghouse screening, document why it is valid.
• Confirm no break in service beyond allowed limits. Record the dates.
• Confirm the person’s prints are retained. Verify arrest notifications are active.
• State the prior employer listed in the Clearinghouse, if shown.
• Add the person to your Clearinghouse roster. This links them to you.

Tip: If there was a long break in service, complete a new screening instead.

Step 6: Address five-year rescreen (if applicable)

• If this is a rescreen, select that reason.
• Enter the new fingerprint date and the new eligibility date.
• Update your tracking log with the next rescreen due date.

Tip: Use a calendar or HR system to track rescreen due dates by person.

Step 7: Address exemptions from disqualification (if applicable)

• If an exemption was approved, check that box.
• Enter the exemption approval date. Record any reference number.
• Attach a copy of the exemption approval letter.
• Confirm the exemption aligns with the current role and duties.

Tip: Do not start work until the exemption approval is on file and verified.

Step 8: Certify compliance

• Read the attestation statements in full.
• Confirm that you verified eligibility in the Clearinghouse.
• Confirm that you will maintain arrest notification monitoring.
• Confirm that you will remove the person from duty if eligibility changes.

Tip: Only an authorized representative should sign this section.

Step 9: Sign and date

• The provider’s authorized representative signs and dates the form.
• Print the signer’s name and title below the signature.
• A notary is not required for this form.

Tip: Use wet signatures or approved e-signatures per your policy.

Step 10: Attach required documentation

• Attach the Clearinghouse eligibility page or result printout.
• Attach the fingerprint receipt for the latest submission.
• Attach the exemption approval, if applicable.
• For contractors, attach the vendor’s roster or confirmation letter, if used.

Tip: Keep documents in the same order across all files. Consistency speeds audits.

Step 11: File and retain

• Place the attestation and attachments in the personnel or vendor file.
• Maintain access-limited storage. Protect personal information.
• Keep the form current. Update if the role changes or status changes.
• Retain for at least five years after separation, unless your license requires longer.

Tip: Add this form to your onboarding checklist and audit plan.

Common Mistakes to Avoid

• Allowing work before eligibility is confirmed. Always verify first.
• Failing to add the person to your Clearinghouse roster. This breaks monitoring.
• Relying on an old result without checking breaks in service.
• Missing five-year rescreen deadlines. Track due dates by person.
• Using nicknames or incomplete legal names. Match identity exactly.
• Forgetting contractors and students. Screen anyone with patient access.
• Not documenting the exemption approval. Keep it attached to the form.
• Leaving fields blank. Use “N/A” only where truly not applicable.

Examples that show correct use

• You hire a CNA who previously worked at a hospital. You verify their Clearinghouse profile shows “Eligible,” prints retained, and arrest notifications active. The CNA left the hospital 30 days ago. You add them to your roster, complete the attestation, and file it.
• Your therapy vendor sends three new therapists to your site. Each therapist appears in the Clearinghouse as “Eligible.” You collect an attestation for each therapist, attach the eligibility pages, and store them in your vendor file. You also confirm the vendor added your facility to each therapist’s roster.
• Your scheduler moves into a patient transport role. You find they were never screened. You submit fingerprints, wait for “Eligible,” complete the attestation, and then start training.
• Your HHA reaches a five-year mark. You submit a rescreen. After “Eligible,” you complete a new attestation and replace the old one on top of the file.

Operational tips to streamline compliance

• Build this form into your onboarding packet. Require it before first shift.
• Use a single point of contact for Clearinghouse checks. This reduces errors.
• Maintain a rescreen calendar with alerts at 90, 60, and 30 days.
• Keep a vendor matrix listing all contractor roles and screening status.
• Run a quarterly audit of attestations against active staff and contractors.
• Train managers not to change duties until HR confirms eligibility.

By following these steps, you will complete the form correctly. You will also have a clear trail showing how you met the rule. That keeps your staff ready to work and your files audit-ready.

Legal Terms You Might Encounter

• Attestation means you formally swear that statements are true. On this form, you attest you completed required screening and meet eligibility.
• Background screening is the process used to check criminal records and related databases. This form documents that your screening is complete and acceptable for your role.
• Level 2 screening is a fingerprint-based check across state and national records. If your role requires it, you confirm on this form that you passed that level.
• A disqualifying offense is a crime that bars you from certain duties by law. When you sign, you confirm you do not have disqualifying offenses, or you have a granted exemption. An exemption from disqualification is an official approval that allows you to work despite a past offense. If granted, you must reflect that status when you sign the form.
• Livescan fingerprints are electronic prints captured by an approved vendor. This is how your Level 2 screening usually occurs before you sign.
• Pending charges are arrests or cases not yet resolved. The form’s statements typically cover pending matters, so you must consider them before signing.
• Arrest vs. conviction is the difference between being charged and being found guilty or pleading guilty. Some programs consider both, so your attestation must be accurate either way.
• Rescreening is a periodic re-check after your initial clearance. When you sign, you may be confirming either a first screen or a rescreen cycle.
• Authorized representative is the person who signs on behalf of the employer or provider. That signature confirms the organization reviewed your results and deems you eligible to work.

FAQs

Do you need to complete this form if you were screened last year?

Yes, if your employer requests it. Employers often need a fresh attestation when you start work, change roles, or rescreen. If your prior results still apply and remain current, you may only need to sign. Your employer will confirm whether a new fingerprint submission is required.

Do you have to list your criminal history on this form?

Typically, no. This form usually confirms your screening status, not a detailed history. You attest that your results show you are eligible, or that you hold an exemption if needed. If the form references pending charges or disqualifying offenses, you must answer truthfully.

Do you need a notary for this form?

Usually, no. Most versions require your signature and date. Some employers add extra steps, like a witness or notary for internal policy reasons. Follow the instructions you receive. If a notary is used, bring photo ID and sign in the notary’s presence.

Do you need to re-fingerprint if you change employers?

Often, yes, but not always. It depends on how your previous results can be verified and whether your new role requires a different screening scope. Your new employer may be able to associate your existing results if still valid. If not, they may ask you to submit new fingerprints.

Do you need to wait for screening results before signing?

Yes. Sign after your results post and your employer has reviewed them. The attestation confirms completion and eligibility. Signing too early can create compliance risks and may be treated as a false statement.

Do you need to disclose new arrests after signing?

Yes. Tell your employer promptly if you are arrested or charged after signing. They may need to pause your direct-care duties or reassess your eligibility. Report updates in writing and keep a copy for your records.

Do you need to renew this form on a schedule?

Many programs require periodic rescreening, often on a multi‑year cycle. Employers may ask you to sign a fresh attestation at each rescreen or when you change positions. Ask your compliance contact when your next rescreen is due.

Do you need your own copy?

Yes. Keep a clean copy of the signed form and proof of your screening. Store them securely. You may need them for audits, role changes, or future employers.

Checklist: Before, During, and After the AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

Before signing

• Confirm your screening status. Ensure your fingerprint-based check is complete and posted.
• Gather ID details. Match your legal name, prior names, and date of birth to your screening record.
• Collect documentation. Have your fingerprint receipt, screening transaction number, and any exemption approval, if applicable.
• Verify employer information. Confirm the correct legal entity name, site, and program identifier your employer uses.
• Confirm your role. Get the exact job title and whether it involves direct contact with clients.
• Address name changes. Bring proof of any recent name change so records align.
• Identify your signers. Know who signs for the employer and whether a witness or notary is needed.
• Review internal policy. Read your employer’s onboarding checklist and retention rules.

During signing

• Use your legal name. Match every letter and suffix to your screening record.
• Fill all required fields. Complete dates, job title, employer name, and any checkboxes.
• Confirm the screening type. Ensure the form reflects the correct level and scope for your role.
• Check eligibility statements. Only sign if the statements match your status and results.
• Note exemptions. If you have an exemption, record any required reference details per your employer’s instructions.
• Sign and date clearly. Use ink if on paper, and print your name and title if requested.
• Avoid corrections. If you must correct, follow your employer’s correction protocol and initial the change.
• Keep it legible. If the reviewer cannot read it, delays follow.

After signing

• Submit to the right contact. Deliver the form to your compliance or HR contact as instructed.
• Confirm receipt. Ask for confirmation that your form is accepted and complete.
• Store your copy. Keep a scanned PDF and the original in a secure file.
• Track next steps. Do not begin restricted duties until your employer confirms final clearance.
• Calendar rescreen dates. Set reminders for any rescreen deadlines your employer provides.
• Update on changes. Report name changes, arrests, or role changes promptly.
• Prepare for audits. Keep your form, screening proof, and exemption documentation together for quick access.

Common Mistakes to in Avoid AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

• Using a nickname or mismatched name. Your screening and the form must match exactly. Don’t forget suffixes and prior names. Consequence: delayed verification and possible rejection.
• Signing before results post. You cannot attest to completion if your screening is still pending. Consequence: possible false statement, onboarding delays, and rework.
• Leaving blanks or missing the date. An undated or incomplete form can be treated as invalid. Consequence: compliance gap and re-submission.
• Ignoring pending charges. If the attestation covers pending matters, you must disclose to your employer. Consequence: removal from duties or termination if discovered later.
• Misstating your role or employer. The form must match the actual job and entity. Consequence: results may not link correctly, causing delays and audit issues.

What to Do After Filling Out AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements

1. Submit the signed form to your designated contact. Follow the delivery method your employer requires. That may be a secure portal or a physical handoff.
2. Wait for confirmation before starting sensitive duties. Your employer must verify that your screening result is eligible and matches your role. Do not assume approval without written clearance.
3. If your result is eligible, complete onboarding. Finish any role-specific training and policy acknowledgments. Your employer will place the form in your personnel or compliance file.
4. If your result shows ineligible, discuss options. You may be able to seek an exemption if allowed for your offense and timeline. Ask your employer how to proceed, and what to submit. You may be reassigned or paused pending resolution.
5. If you discover an error, correct it promptly. Tell your employer, void the incorrect form, and sign a clean corrected version. Keep both versions and a note explaining the correction for audit clarity.
6. If you change roles or locations, check whether you need a new form. Many employers require a fresh attestation when role duties change. Confirm any additional screening needed.
7. Maintain your records. Keep your signed form, proof of screening, and any exemption approvals. Store them securely and back them up. You will thank yourself during audits or future job changes.
8. Plan for rescreening. Ask for your rescreen date and internal reminders. Put it on your calendar with a buffer. Start the process early to avoid gaps in work eligibility.
9. Inform your employer about material changes. Report name changes, arrests, or new charges right away. Provide supporting documents as requested. Keep copies of everything you submit.
10. Stay proactive. If you do not receive clearance by the expected date, follow up. Delays often stem from small data mismatches you can fix quickly.