Long-term Care Background Check and Home & Community-Based Services Background Check and Attestation Form
By signing this form, I consent to the submission of a request for a criminal records check (including database reviews) for long-term care and community-based service workers, as required by the Ohio Revised and Administrative Codes.
This request will be submitted by Eliza Jennings to the Bureau of Criminal Investigation prior to employment and every five years if applicable and as determined by my employment status and location of employment.
I also attest to the following:
1. That I have not been convicted or plead guilty to any of the crimes that would disqualify me from working with older adults under Ohio Administrative Code 3701-13-05 and 3701-60-06.
2. That I understand and agree that if I am found to have a record of any of those crimes, or if Eliza Jennings does not receive a response from BCI/FBI within 30 days, I will not be hired for work with older adults or, if I have already been hired, that my conditional employment will be terminated.
3. That I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment.