Long-term Care Background Check and Home & Community-Based Services Background Check Consent and Attestation Form
By signing this form, I consent to submission of a request for criminal records check (including database reviews) for long-term care and community-based services workers, as required by the Ohio Administrative and Revised Codes.
This request will be submitted by Eliza Jennings to the Bureau of Criminal Investigations 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 of, or plead guilty to, any of the crimes that would disqualify me from working and volunteering with older adults under Senate Bill 160.
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 permitted to work/volunteer with older adults or, if I have already begun working/volunteering, that my conditional employment/volunteering 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 working/volunteering.