By signing this form, I consent to the submission of a request for a criminal record check for direct care workers as required by Ohio Rule 5123:2-2-02, Background Investigations for Employment. Siffrin will submit the request to BCI in London, Ohio. The check will include a search of Ohio records and may or may not include an FBI check of the United States.
I attest to the following:
I have not been convicted or plead guilty to any of the offenses that would disqualify me from working with ID/DD individuals under Ohio Rule 5123:2-2-02, Background Investigations for Employment. I have viewed a list of disqualifying offenses. I do not have any offenses on my record that would be in conflict with the requirements of the position or agency policy based upon the job description that I have reviewed. I have had the opportunity to ask any questions that I may have about any specific charges.
I understand and agree that if I am found to have a record of any of those offenses, I will not be hired for work with ID/DD individuals or, if I have already been hired, my employment will be terminated.
I understand that if I am employed by the agency, I am responsible to report to them within 14 calendar days any change to the status of my background check. This would include my being charged with an offense, being convicted of an offense, or by pleading guilty to an offense that is on Ohio Rule 5123:2-2-02, Background Investigations for Employment, or in conflict with the agency’s policy or the requirements of the position.
I further understand that my failure to do so may result in my immediate termination from the agency.
I was informed that I must provide fingerprint impressions and that a criminal record check must be conducted if I come under final consideration for employment.
I understand that the following checks are required before my employment with Siffrin, Inc. I understand that if I have any violations come back on these potential checks below I am not eligible for hire with Siffrin, Inc.
- Nurse’s Aide Registry
- Abuser Registry
- Driver’s License Check
- List of Excluded Person’s
- Sex and Child Offender’s
- United States General Services
- Incarcerated and Supervised Offenders
I understand that if employed by the agency I am responsible to report to them within 14 calendar days any change to the status of these required checks.
I further understand that my failure to do so may result in my immediate termination from the agency.
Motor Vehicle Check
As part of the application and hiring process, we are required to complete a driving record check for you. This is done in compliance with the agency’s automobile insurance policy requirements.
Please read over the attached list if violations carefully.
In the past three years, if you have one or more of the Type A violations, you are not eligible for employment with the agency.
Also, if you have three or more Type B violations in the past three years, you are also not eligible for employment.
The agency guidelines also state that you may not have more than 4 points and/or two convictions within that past three years for drivers, two years for any other staff.
Please ask if you have any questions.
Thank you,
Tara MacLean, Director of Human Resources
Type A Violations
DWI/DUI/DWUI-Drugs or Alcohol
Refusing to take a substance test
Driving with an open container
Negligent homicide using a motor vehicle
Driving while license is suspended or revoked
Operating a motor vehicle for the commission of a felony
Aggravated assault with a motor vehicle
Permitting an unlicensed person to drive
Reckless driving
Fleeing or evading police or roadblock
Resisting arrest
Speed contest (racing)
Hit and run
Failure to report an accident
Illegal passing of a school bus
Other violations considered serious by state law
Type B Violations
Speeding
Improper lane change
Failure to yield
Failure to obey a traffic signal or sign
Careless driving
Accidents
By signing this form, I consent to the submission of a request for a motor vehicle report. I understand that I am entitled to a copy of my report and that I must only request this through the HR Department should I desire it.
I attest to the following:
I have reviewed a list of Type A and Type B violations that may or may not be included on my motor vehicle report.
I have had the opportunity to ask any questions that I may have about any specific violations.
I understand and agree that I must meet the agency’s insurance policy requirement with respect to my driving record in order to be considered for any position that would require me to drive.
I understand that if employed by the agency I am responsible to report to them within 14 calendar days any change to the status of my motor vehicle report.
I further understand that my failure to do so may result in my immediate termination from the agency.
Substance Screening Consent and Release
As an employee/applicant of Siffrin, Inc. I hereby acknowledge the agency policy, which requires me to submit to urine testing and/or breath alcohol testing.
I further understand that the purpose of this analysis is to determine or rule out the presence of non-prescribed or prohibited dangerous controlled substances in my system,
I hereby freely and voluntarily consent to this request for a urine sample and/or breath alcohol test and agree to participate in the testing program.
I hereby and herewith release Siffrin, its employees, agents, and contractors from any and all liability whatsoever arising from this request for testing, from the actual testing procedures, and from decisions made concerning my application for or consideration of employment based on the results if the analysis.
I agree to cooperate in all aspects of the testing procedure.
I agree that my signature on this form is my authorization to have the cost of the drug screening deducted from my paycheck in the event the results are positive, and I am ineligible for employment with Siffrin, Inc.
I hereby authorize the release of my drug and/or alcohol test results to the contractor’s Medical Review Officer (MRO).
I further acknowledge that the agency has provided me with an opportunity to ask questions related to its drug and alcohol testing program and that all my questions have been answered.