Join Now Form

Equal access to employment is available to all persons. Those applicants requiring reasonable accommodation for the application and/or interview process should notify the Personnel Director

EMPLOYMENT HISTORY

Provide the following from your past and current employers, assignments or volunteer activities - starting with the most recent (use additional sheets if necessary).

POSITION APPLIED FOR:
Date Available For Work:		Salary Desired:
Are you currently employed?	YesNo
Referred by:

EDUCATIONAL BACKGROUND
	NAME & SCHOOL LOCATION	NO. OF YEARS ATTENDED	DID YOU GRADUATE?	DEGREE/DIPLOMA
HIGH SCHOOL			YesNo
COLLEGE			YesNo
TRADE,BUSINESS/CORRESPONDENCE SCHOOLS			YesNo

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions,
or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time.
I give the employer the right to contact and obtain information from all references, employers, and educational institutions and otherwise verify the
accuracy of the information contained in this application. I hereby release from liability to the employer and its representatives for seeking,
gathering, and using such information and all other persons, corporations or organizations for furnishing such information.
The employer does not unlawfully discriminate in employment and no question on this application is used for the purposes of limiting or excusing any
applicant from consideration for employment on a basis prohibited by local, state or federal law.
The employer reserves the same right to terminate my employment at any time with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period of definite duration.
I understand that it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a
reasonable accommodation as required by the ADA and Section 504 of the Rehabilitation Act.
I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.
I have read and fully understand the foregoing and seek employment under these conditions.

Signature of Applicant
Date

JOB DESCRIPTION REVIEW

I have read and understood the job description for the position of Home Health Aide.

Signature of Applicant
Date

EXCLUSION CHECKS AND RECORD RETENTION ACKNOWLEDGMENT

I acknowledge that J.A.K. INDEPENDENT SERVICES LLC has informed me of the exclusion checks that will be performed on my name and social security number. I am aware that the OIG, SEX OFFENDER, INMATE, ABUSER REGISTRY, NURSE AIDE, SAMS, AND MEDICAID exclusions will be performed before I am hired. I am also aware that once I am hired, these exclusion results will be kept on file with this agency for six (6) years or more.

My signature indicates that I am fully aware and give my consent for these searches to be performed

Employee Printed Name
Employee Signature
Date

ABUSER REGISTRY ANNUAL NOTICE

The Ohio Department of Developmental Disabilities (Department") maintains an Abuser Registry which is a list of employees who the Department has determined have committed one of the Registry offenses listed below. If your name is placed on the Registry you are barred from employment as a Developmental Disabilities employee in the state of Ohio. Because other state agencies require employers to check the Abuser Registry, placement on the Registry also prohibits you from being employed (1) by a Medicaid agency, being an owner (5 percent or more) of an agency or having a Medicaid Provider Agreement as a nonagency provider; (2) in a position to provide Ombudsman services or direct care services to anyone enrolled in a program administered by the Ohio Department of Aging: and (3) by a home health agency in a direct care position and may prevent you from being hired in a nursing home or residential care facility in a direct care position.
After 1 year, the person may petition the Department for removal of their name from the Registry. If the petition is denied, the name remains on the Registry. The name of any "Developmental Disabilities (DD) employee" may be placed on the Registry. DD employee includes any Department employee, any employee of a county board of DD, an independent provider under Ohio Revised Code section 5123.16, and any employee providing specialized services to an individual with developmental disabilities. A specialized service is a program or service designed to primarily serve individuals with developmental disabilities including services by an entity licensed or certified by the Department.

Abuser Registry Offenses:

Physical Abuse - the use of any physical force that could reasonably be expected to result in physical harm.
Sexual Abuse - unlawful sexual conduct (unprivileged intercourse or other sexual penetration) and unlawful sexual contact (unprivileged touching of another's erogenous zone).
Verbal Abuse - purposely using words to threaten, coerce, intimidate, harass or humiliate an individual.
Prohibited Sexual Relations- Consensual touching of an erogenous zone for sexual gratification and the individual is in the employee's care and the individual is not the employee's spouse.
Neglect - when there is a duty to do so, failing to provide an individual with any treatment, care, goods or services nosary to maintain the health or safety of the individual
Misappropriation (Theft) - obtaining the property of an individual or individuals, without consent, with a combined value of at least $100. Theft of the individual's prescribed medication, check,credit card, ATM card and the like are also Registry offenses.
Failure to Report Abuse, Neglect or Misappropriation - the employee unreasonably does not report abuse, neglect or misappropriation of the property of an individual with developmental disabilities, or the substantial risk to such an individual of abuse, neglect or misappropriation, when the employee should know that their non-reporting will result in a substantial risk of harm to such individual.
Conviction or plea of guilty to: Offense of Violence - R. C. 2901.01, including convictions for the offense of Assault, Menacing, Domestic Violence or Attempting to commit any offense of violence; Sexual Offenses - R. C. Chapter 2907; Theft Offenses - R. C. Chapter 2913; Failing to provide for a functionally impaired person - RC. 2903.16; Patient Abuse or Neglect - RC. 2903.34; Patient Endangerment - 2903.341; and/or Endangering Children - 2919.22.

More information is available on the Department's website under the Health and Safety tab.
The Registry website is at: https://its.prodapps.dodd.ohio.gov/ABR Default.aspx.
Please call the Department at 614-995-3810 with any questions regarding the Registry.

I have received a copy of the Abuser Registry Annual Notice. I understand that I am responsible for reading and understanding the materials that are contained in it.

Signature of Employee
Employee Name
Date Signed

Attestation and Agreement to Notify Employer

I hereby attest that I have not been convicted of or pleaded guilty to any of the disqualifying offenses listed below and agree that I will notify JAK INDEPENDENT SERVICES LLC within 14 calendar days, if while employed I am formally charged with, am convicted of, or plead guilty to one of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.

Applicant's Signature
Applicant's Name Printed
Date Signed

J.A.K. INDEPENDENT SERVICES LLC REQUEST FOR COPY OF BACKGROUND CHECK

173.38/BCI173.41/FBI
INDIVIDUALS'S NAME
INDIVIDUAL'S SOCIAL SECURITY NUMBER
INDIVIDUAL'S DATE OF BIRTH

MY SIGNATURE INDICATE THAT I GIVE J.A.K. LLC PERMISSION TO REQUEST A COPY OF MY BIC FOR THE PURPOSE OF RETAINING A JOB WITH THEIR AGENCY.

INDIVIDUALS'S SIGNATURE
DATE
MGT>. SIGNATURE AND TITLE
DATE

PERSONAL INFORMATION



Are you 18 years or older? (required)	YesNo
If hired, can you supply the required documentation to verify your lawful right to work in the United States? (required)	YesNo

	Dates Employed From	Dates Employed To




MAY WE CONTACT FOR REFERENCE ?	YesNo

	Dates Employed From1	Dates Employed To1




MAY WE CONTACT FOR REFERENCE ?	YesNo

	Dates Employed From	Dates Employed To




MAY WE CONTACT FOR REFERENCE ?	YesNo

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