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,

    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.