Employment Application
Full Name (required)
Date (required)
Address (required)
City, State, ZIP (required)
Phone (required)
Email (required)
Date Available (required)
Social Security No. (required)
Desired Salary (required)
Position Applied for (required)
Are you a citizen of the United States? (required)
YesNo
If no, are you authorized to work in the U.S.? (required)
Have you ever worked for this company? (required)
If yes, when?
Have you ever been convicted of a felony? (required)
If yes, explain
Fact Sheet: Universal Precautions
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.
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
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.
By signing I (required)
Verify that I have read and acknowledged the above information and any questions regarding the above have been addressed with a Strive for Independence Manager to satisfaction.
Signature (required)
FORMS: A. Vehicle Usage Waiver
Employee (required)
Driver's License # (required)
State (required)
License Plate # (required)
Make/Model (required)
Waiver Conditions
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
Abuser Registry Annual Notice
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.
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.
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.
I acknowledge and understand the information presented above.
The Bill of Rights for Persons with Developmental Disabilities
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 verify that I have read and acknowledged the above information and any questions regarding the above have been addressed with a Strive for Independence Manager to satisfaction.
Employee Receipt and Acceptance
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.
Employee Signature (required)
Confidentiality Policy and Pledge
*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.
Job Description - Direct Support Professional
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.
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.
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.
Exhibits professional behavior at all times.
Maintain the property of the client and Safe Harbor Home Healthcare.
Network and build with other coworkers.
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.
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.
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.
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.
Employee Name (Print) (required)
Supervisor Name (Print) (required)
Supervisor Signature (required)
Attestation and Agreement to Notify Employer
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,
Employer's Name (required)
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.
Applicant's Signature (required)
Date Signed (required)
Applicant's Name Printed (required)
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.
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
2923.12
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
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
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
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
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
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
