Employment Application Form

Please complete all forms to submit an application.


    Blood and other body fluids (i.e., semen, vaginal fluids, saliva, urine, feces, vomit) can contain viruses and bacteria that can be passed on to another person through direct contact. Hepatitis B & C and HIV are diseases that can be transferred from one person to another through contact with infected blood and/or body fluids. Since there is no way to know without testing if a person has hepatitis B or C or HIV, it is recommended that you treat all body fluids as though they were infected.

    Universal Precautions are actions that you take to place a barrier between yourself and potentially infected body fluids.

    How are blood and body fluids passed from one person to another?

    • Through open areas on the skin

    • By splashing in the eye

    • Through the mouth

    • Unprotected sexual activity (oral, anal, and vaginal)

    • Injury with contaminated needles or other sharps

    • Prenatally (mother to baby) and during delivery

    How can I protect myself from blood and body fluids?

    The easiest way to protect yourself from blood and body fluids is to have the injured person treat their own wound. If they are unable to take care of themselves, or they need some help, use latex gloves. If you do not have disposable gloves available, use a plastic bag (trash, shopping, or sandwich) over your hands to create a barrier. Your employer must provide appropriate personal protective equipment (gloves, goggles, disinfectant, etc.) for your use while at work. Know where these items are located so that you will be better prepared to protect yourself.


    • I understand that I may be required to use my personal vehicle to transport individuals during working hours.

    • When transporting individuals, I will at all times practice safe driving techniques and strictly adhere to all traffic safety laws.

    • When transporting individuals, I will ensure that all vehicle occupants are wearing seatbelts.

    • I will provide Convenient Care with a copy of my current driver's license and each time my license is renewed I will provide Convenient Care with a copy.

    • I will maintain liability coverage during my employment and provide Convenient Care with insurance documentation, as needed, to verify automobile coverage.

    • During scheduled working hours I will use my personal vehicle for work-related tasks only.

    • I will transport individuals only in the vehicle identified above. If at any point I change vehicles I will complete a new Vehicle Usage Agreement.

    • I will immediately notify Convenient Care of any and all traffic violations, or changes in insurance coverage, which may affect my ability to use my personal vehicle to perform job duties.

    • I will at all times keep my vehicle in safe operating condition, including but not limited to, and ensuring the following:

      • Rearview mirror and side mirrors present and in good working condition

      • Headlights (bright and dims) in proper working order

      • Stop, parking, and turn signals (front and rear) work properly

      • Windshield wipers work and blades are in good condition

      • Tires have good tread and are free from damage (no breaks, cuts, or bulges)

      • Seatbelts are free from wear and tear and working properly

      • Working horn

      • Brakes are in proper working order

      • The interior and exterior of the vehicle are in safe condition


    The Ohio Department of Developmental Disabilities (“Department”) maintains an Abuser Registry which is a list of DD employees who the Department has determined have abused, neglected, had sexual contact with, stolen property from, or did not report the abuse or neglect of an individual with DD. If your name is placed on the Abuser Registry you are barred from employment as a DD employee in this state for a minimum of 5 years.

    Employees whose names may be placed on the Abuser Registry

    • Any “DD employee” may be placed on the Abuser Registry. DD employee includes any Department employee, any employee of a county board of DD, and any employee providing specialized services to an individual with DD. A specialized service is a program or service designed to primarily serve individuals with DD including services by an entity licensed or certified by the Department.

    Abuser Registry Offenses

    The Department may place the name of an MR/DD employee on the Abuser Registry if it determines that the employee has committed any of the below offenses against an individual with DD.

    • Abuse:

      • Abuse includes the use of any physical force that could reasonably be expected to result in physical harm.

      • Abuse includes unlawful sexual conduct (unprivileged intercourse or other sexual penetration) and unlawful sexual contact (unprivileged touching of another’s erogenous zone).

      • Abuse includes verbal abuse. Verbal abuse means purposely using words to threaten, coerce, intimidate, harass or humiliate an individual.

    • Sexual Contact:

      • Sexual contact means the touching of an erogenous zone for sexual gratification, whether or not consensual, by any DD employee of an individual in the employee’s care who is not the employee’s spouse.

    • Neglect:

      • Neglect means, when there is a duty to do so, failing to provide an individual with any treatment, care, goods, or services necessary to maintain the health or safety of the individual.

    • Misappropriation (theft):

      • This means obtaining the property of an individual or individuals, without consent, with an aggregate (combined) value of at least $100. Theft of any check, credit card, ATM card, and the like are also Abuser Registry offenses.

    • Failure to Report Abuse, Neglect, or Misappropriation:

      • A DD employee may be placed on the Abuser Registry if the employee unreasonably does not report abuse, neglect, or misappropriation of the property of an individual with MR/DD, or the substantial risk to such an individual of abuse, neglect, or misappropriation, when the employee should know that his/her non-reporting will result in a substantial risk of harm to such individual.


    • Be treated nicely at all times and as a person.

    • Have a clean safe place to live in and a place to be alone.

    • Have food that is good for you.

    • Be able to go, if you want, to any church, temple, mosque.

    • Be able to go to a doctor or dentist when you are sick.

    • Be able to have people help you with the way you walk, talk, do things with your hands, act or feel, if you need it.

    • Be able to have people help and teach you, if you want.

    • Be able to have time and a place to go to be by yourself.

    • Be able to call, write letters, or talk to anyone you want about anything you want.

    • Be able to have your own things and be able to use them.

    • Be able to join in activities and do things that will help you grow to be the best person you can be.

    • Be able to work and make money.

    • Be treated like everyone else.

    • Not be hit, yelled at, cursed at, or called names that hurt you.

    • Be able to learn new things, make friends, have activities to do, and go out in your community.

    • Be able to tell people what you want and be part of making plans or decisions about your life.

    • Be able to ask someone you want to help you, let others know how you feel or what you want.

    • Be able to use your money to pay for things you need and want with help, if you need it.

    • Be able to say yes or no before people talk about what you do at work or home or look at your file.

    • Be able to complain or ask for changes if you don't like something without being afraid of getting in trouble.

    • Not be given medicine that you don't need, or be held down if you are not hurting yourself or others.

    • To vote and learn about laws and your community.

    • To say yes or no to being part of a study or experiment.


    I hereby acknowledge receiving the Safe Harbor Home Healthcare employee manual. I hereby understand that it’s my responsibility to read, understand, and comply with all rules and policies of the company. I understand that I have the right to resign from my position. Also, I understand that Safe Harbor Home Healthcare has the right to terminate my employment with or without notice.


    *CONFIDENTIALITY OF CLIENT’S RECORDS*

    All information that an employee learns about Safe Harbor Home Healthcare, our clients, clients' medical or personal records as a result of working for the company is considered confidential information. This information is not made available to the public. Employees may not disclose confidential information to anyone that is not employed by Safe Harbor Home Healthcare.

    Disclosure or distribution of Safe Harbor Home Healthcare confidential information is prohibited.

    I have read and understand the above policy.


    Safety: Security, Environment and Health:

    • Maintain a calm, healthy, and safe environment for all clients.

    • Administer medications as directed by the Medical Provider.

    • Assist individuals with healthcare visits in the community.

    • Notify direct supervisor of any immediate concerns.

    • Provide support for all Activities of Daily Living.

    Rights, Dignity and Respect:

    • Provide care for all clients according to the ISP.

    • Maintain confidentiality with all client and Safe Harbor Home Healthcare information.

    • Treat all clients, families, and staff with respect.

    • Seek and provide opportunities where clients can make their own choices.

    Community Engagement:

    • Foster healthy relationships between the client and the community.

    • Assist clients with a client-centered schedule.

    • Encourage clients to be involved in their community.

    • Support clients in activities of their choosing.

    Customer Service:

    • Exhibits professional behavior at all times.

    • Maintain the property of the client and Safe Harbor Home Healthcare.

    • Network and build with other coworkers.

    Accountability:

    • Maintain all client finances under the direction of the supervisor.

    • Compliant with all agency rules and procedures.

    • Compliant with daily documentation and provides receipts of all purchases to the supervisor.

    Conduct:

    • Maintains a positive and appropriate attitude at all times.

    • Mentor and train all new staff.

    • Reports all concerns to the direct supervisor.

    • Attends and participates in all company meetings and events.

    DSP Qualifications:

    • At least 18 years of age.

    • Valid Driver’s License, acceptable driving history, and proof of insurance.

    • High School Diploma or GED.

    • Ability to pass mandatory drug screen and physical.

    • Ability to pass a criminal background check.

    • Ability to work with individuals with challenging behavior.

    • Ability to assist clients with Activities of Daily Living.

    Acknowledgment of Receipt:

    I have reviewed and received a copy of the DSP Job Description. I understand my position and role in this company. I acknowledge that I am responsible for fulfilling the requirements, qualifications, and duties of this job.


    I hereby attest that I have not: 1) been convicted of, 2) pleaded guilty to, or 3) been found eligible for intervention in lieu of conviction, for any of the disqualifying offenses listed below and agree that I will notify my employer,

    within 14 calendar days, if while employed, I am formally charged with, am convicted of, plead guilty to, or am found eligible for intervention in lieu of conviction for any of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.

    Tier 1 Disqualifying Offenses (Permanent Exclusion):

    2903.01

    Aggravated murder

    2903.02

    Murder

    2903.03

    Voluntary manslaughter

    2903.11

    Felonious assault

    2903.15

    Permitting child abuse

    2903.16

    Failing to provide for a functionally impaired person

    2903.34

    Patient abuse and neglect

    2903.341

    Patient endangerment

    2905.01

    Kidnapping

    2905.02

    Abduction

    2905.32

    Human trafficking

    2905.33

    Unlawful conduct with respect to documents

    2907.02

    Rape

    2907.03

    Sexual battery

    2907.04

    Unlawful sexual conduct with a minor, formerly corruption of a minor

    2907.05

    Gross sexual imposition

    2907.06

    Sexual imposition

    2907.07

    Importuning

    2907.08

    Voyeurism

    2907.12

    Felonious sexual penetration

    2907.31

    Disseminating matter harmful to juveniles

    2907.32

    Pandering obscenity

    2907.321

    Pandering obscenity involving a minor

    2907.322

    Pandering sexually oriented matter involving a minor

    2907.323

    Illegal use of minor in nudity-oriented material or performance

    2909.22

    Soliciting/providing support for act of terrorism

    2909.23

    Making terrorist threat

    2909.24

    Terrorism

    2913.40

    Medicaid fraud

    2923.01

    Conspiracy when the underlying offense is any of the offenses or violations on this list

    2923.02

    Attempt when the underlying offense is any of the offenses or violations on this list

    2923.03

    Complicity when the underlying offense is any of the offenses or violations on this list

    A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (Illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits).

    A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

    Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

    2903.04

    Involuntary manslaughter

    2903.041

    Reckless homicide

    2905.05

    Criminal child enticement

    2909.03

    Arson

    2909.11

    Aggravated arson

    2911.01

    Aggravated robbery

    2911.11

    Aggravated burglary

    2913.46

    Illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits

    2913.48

    Workers' compensation fraud

    2913.49

    Identity fraud

    2917.02

    Aggravated riot

    2923.01

    Conspiracy when the underlying offense is any of the offenses or violations on this list

    2923.02

    Attempt when the underlying offense is any of the offenses or violations on this list

    2923.03

    Complicity when the underlying offense is any of the offenses or violations on this list

    2923.12

    Carrying concealed weapon

    2923.122

    Illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone

    2923.123

    Illegal conveyance, possession, or control of deadly weapon or dangerous ordnance into courthouse

    2923.13

    Having weapons while under disability

    2923.161

    Improperly discharging a firearm at or into a habitation or school

    2923.162

    Discharge of firearm on or near prohibited premises

    2923.21

    Improperly furnishing firearms to minor

    2923.32

    Engaging in pattern of corrupt activity

    2923.42

    Participating in criminal gang

    2925.02

    Corrupting another with drugs

    2925.03

    Trafficking in drugs

    2925.04

    Illegal manufacture of drugs or cultivation of marihuana

    2925.041

    Illegal assembly or possession of chemicals for the manufacture of drugs

    3716.11

    Placing harmful objects in food or confection

    A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

    Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

    959.13

    Cruelty to animals

    959.131

    Prohibitions concerning companion animals

    2903.12

    Aggravated assault

    2903.21

    Aggravated menacing

    2903.211

    Menacing by stalking

    2905.12

    Coercion

    2909.04

    Disrupting public services

    2911.02

    Robbery

    2911.12

    Burglary

    2913.47

    Insurance fraud

    2917.01

    Inciting to violence

    2917.03

    Riot

    2917.31

    Inducing panic

    2919.22

    Endangering children

    2919.25

    Domestic violence

    2921.03

    Intimidation

    2921.11

    Perjury

    2921.13

    Falsification, falsification in theft offense, falsification to purchase firearm, or falsification to obtain a concealed handgun license

    2921.34

    Escape

    2921.35

    Aiding escape or resistance to lawful authority

    2921.36

    Illegal conveyance of weapons, drugs, or other prohibited items onto grounds of detention facility or institution

    2923.01

    Conspiracy when the underlying offense is any of the offenses or violations on this list

    2923.02

    Attempt when the underlying offense is any of the offenses or violations on this list

    2923.03

    Complicity when the underlying offense is any of the offenses or violations on this list

    2925.05

    Funding of drug or marihuana trafficking

    2925.06

    Illegal administration or distribution of anabolic steroids

    2925.24

    Tampering with drugs

    2927.12

    Ethnic intimidation

    A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

    Tier 4 Disqualifying Offenses (Five-Year Exclusion):

    2903.13

    Assault

    2903.22

    Menacing

    2907.09

    Public indecency

    2907.24

    Soliciting after positive human immunodeficiency virus test

    2907.25

    Prostitution

    2907.33

    Deception to obtain matter harmful to juveniles

    2911.13

    Breaking and entering

    2913.02

    Theft

    2913.03

    Unauthorized use of a vehicle

    2913.04

    Unauthorized use of property, computer, cable, or telecommunication property

    2913.05

    Telecommunications fraud

    2913.11

    Passing bad checks

    2913.21

    Misuse of credit cards

    2913.31

    Forgery, forging identification cards

    2913.32

    Criminal simulation

    2913.41

    Defrauding a rental agency or hostelry

    2913.42

    Tampering with records

    2913.43

    Securing writings by deception

    2913.44

    Personating an officer

    2913.441

    Unlawful display of law enforcement emblem

    2913.45

    Defrauding creditors

    2913.51

    Receiving stolen property

    2919.12

    Unlawful abortion

    2919.121

    Unlawful abortion upon minor

    2919.123

    Unlawful distribution of an abortion-inducing drug

    2919.23

    Interference with custody

    2919.24

    Contributing to unruliness or delinquency of child

    2919.25

    Domestic violence

    2921.12

    Tampering with evidence

    2921.21

    Compounding a crime

    2921.24

    Disclosure of confidential information

    2921.32

    Obstructing justice

    2921.321

    Assaulting/harassing police dog or horse/service animal

    2921.51

    Impersonation of peace officer

    2923.01

    Conspiracy when the underlying offense is any of the offenses or violations on this list

    2923.02

    Attempt when the underlying offense is any of the offenses or violations on this list

    2923.03

    Complicity when the underlying offense is any of the offenses or violations on this list

    2925.09

    Illegal administration, dispensing, distribution, manufacture, possession, selling, or using any dangerous veterinary drug

    2925.11

    Drug possession other than a minor drug possession offense

    2925.13

    Permitting drug abuse

    2925.22

    Deception to obtain dangerous drugs

    2925.23

    Illegal processing of drug documents

    2925.36

    Illegal dispensing of drug samples

    2925.55

    Unlawful purchase of pseudoephedrine product

    2925.56

    Unlawful sale of pseudoephedrine product

    A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

    Tier 4 Disqualifying Offenses (Five-Year Exclusion):

    2903.13

    Assault

    2903.22

    Menacing

    2907.09

    Public indecency

    2907.24

    Soliciting after positive human immunodeficiency virus test

    2907.25

    Prostitution

    2907.33

    Deception to obtain matter harmful to juveniles

    2911.13

    Breaking and entering

    2913.02

    Theft

    2913.03

    Unauthorized use of a vehicle

    2913.04

    Unauthorized use of property, computer, cable, or telecommunication property

    2913.05

    Telecommunications fraud

    2913.11

    Passing bad checks

    2913.21

    Misuse of credit cards

    2913.31

    Forgery, forging identification cards

    2913.32

    Criminal simulation

    2913.41

    Defrauding a rental agency or hostelry

    2913.42

    Tampering with records

    2913.43

    Securing writings by deception

    2913.44

    Personating an officer

    2913.441

    Unlawful display of law enforcement emblem

    2913.45

    Defrauding creditors

    2913.51

    Receiving stolen property

    2919.12

    Unlawful abortion

    2919.121

    Unlawful abortion upon minor

    2919.123

    Unlawful distribution of an abortion-inducing drug

    2919.23

    Interference with custody

    2919.24

    Contributing to unruliness or delinquency of child

    2919.25

    Domestic violence

    2921.12

    Tampering with evidence

    2921.21

    Compounding a crime

    2921.24

    Disclosure of confidential information

    2921.32

    Obstructing justice

    2921.321

    Assaulting/harassing police dog or horse/service animal

    2921.51

    Impersonation of peace officer

    2923.01

    Conspiracy when the underlying offense is any of the offenses or violations on this list

    2923.02

    Attempt when the underlying offense is any of the offenses or violations on this list

    2923.03

    Complicity when the underlying offense is any of the offenses or violations on this list

    2925.09

    Illegal administration, dispensing, distribution, manufacture, possession, selling, or using any dangerous veterinary drug

    2925.11

    Drug possession other than a minor drug possession offense

    2925.13

    Permitting drug abuse

    2925.22

    Deception to obtain dangerous drugs

    2925.23

    Illegal processing of drug documents

    2925.36

    Illegal dispensing of drug samples

    2925.55

    Unlawful purchase of pseudoephedrine product

    2925.56

    Unlawful sale of pseudoephedrine product

    A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.