Care Provider Background Screening Clearinghouse Request Form

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Care Provider Background Screening Clearinghouse
Background Screening Request Form
You have applied for a position with a health care and/or service provider regulated by a specified agency in the Care Provider Background Screening Clearinghouse (Clearinghouse) that requires a fingerprint-based background check. As a health care and/or service provider regulated by a specified agency in the Clearinghouse we may conduct a search for an existing background screening result or submit a new background screening request through the Clearinghouse results website on your behalf.

In order to complete the search and/or background screening request we must collect the following information. This information is required by the Clearinghouse, the Florida Department of Law Enforcement, and the Federal Bureau of Investigation.

NOTE FOR APPLICANTS WITH BACKGROUND CONCERNS: If you have ever been charged for a criminal offense for any reason, you may want to review the list of disqualifying offenses before requesting a review by Pasco County Schools. If you were charged and found guilty for any of the charges highlighted in yellow on the list, you will not be eligible to be a vendor nor work in any capacity in Pasco County Schools. Please note that your plea in a case is equally important as the outcome. If you plead "guilty" or "no contest" to any of the charges on the list, regardless of adjudication, it will have the same effect as having been found guilty for employment purposes, and you will not be eligible to be a vendor. The district may also consider frequency, recency and severity of other charges listed to make a determination of suitability to work as a vendor in Pasco County Schools.
Did you complete a background screening on or before April 6, 2025?
If "Yes", STOP completing this form. Please complete the FSSR form located on our district website.
Name Name First Middle Last
Social Security Number (without dashes)
*This data will be encrypted for your protection*
Date of Birth Date of Birth / MM / DD YYYY
Place of Birth (State or Country if outside of the USA)

If you are not working with a company/agency, provide the name under which you will be doing business or providing services in Pasco County Schools.
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email (Privacy Policy will be sent to this email)
Telephone Number Telephone Number - ### - ### ####
Sex
Race
Hair Color
Eye Color
Height (Ex. 5'7")
Weight
COMPANY OR AGENCY INFORMATION
Company/Agency Name

If you are not working with a company/agency, provide the name under which you will be doing business or providing services in Pasco County Schools.
Company/Agency Address Company/Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of the Company/Agency Contact

The Contact is the person at the company/agency that needs to receive the information regarding the District's review of your background screening results.
Email of the Company/Agency Contact
(Copy of your notifications will be sent here)

Notifications will be sent to this email address. If you are not working with a company, please re-enter your own email address.
Upload the Verification of Eligibility for Employment in the US (I-9 Form)

Attach Files

I-9's are issued by your employer. A copy must be submitted to the district per Florida Statute 1012.467.

Interns and other non-paid personnel are not required to upload an I-9.
Telephone Number of Company/Agency Contact Telephone Number of Company/Agency Contact - ### - ### ####
Type of contact / access:

Type of contact / access: Vendor will have DIRECT contact with students or WILL have access to or control of school funds Vendor will have INDIRECT contact with students and will have NO ACCESS to or NO CONTROL of school funds Vendor will have NO STUDENT CONTACT (works off campus or when students are not present)
If you are having difficulty submitting the form or have any questions or concerns, you may contact us by email or telephone.

Email: CHscreening@pasco.k12.fl.us
Phone: (727) 774-2521

Care Provider Background Screening Clearinghouse Request Form

If "Yes", STOP completing this form. Please complete the FSSR form located on our district website.

COMPANY OR AGENCY INFORMATION

If you are having difficulty submitting the form or have any questions or concerns, you may contact us by email or telephone. Email: CHscreening@pasco.k12.fl.us Phone: (727) 774-2521

If you are having difficulty submitting the form or have any questions or concerns, you may contact us by email or telephone.

Email: CHscreening@pasco.k12.fl.us
Phone: (727) 774-2521