DIVISION OF PAROLE AND COMMUNITY SERVICES Parole Officer Assessment Packet

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1 DIVISION OF PAROLE AND COMMUNITY SERVICES Parole Officer Assessment Packet Requirements for Employment January 2007 Attached, you will find a map of the seven Adult Parole Authority Regions, the Parole Officer Regional Request form, Authority for Release of Information form,, and instructions. The Parole Officer Regional Request form, Authority for Release of Information, and Parole Officer Background Questionnaire must be completed and returned to the Ohio Corrections Assessment Center. The completed forms must be mailed to the following address and postmarked no later than March 12, 2007 to be considered timely. Failure to receive the original forms completed in full by the required date will eliminate you from further consideration. Ohio Corrections Assessment Center ATTN: S. Pennington, Coordinator P.O. Box 210 Orient, Ohio The Parole Officer Regional Request form will allow you to select the region where you are most willing to accept employment. You may only select one (1) region. Once you have identified the region, you must then select the counties within the region. You are not required to select all of the counties within a region; however, you may only choose counties in the region you have selected. Indicate the counties in order of preference with number one (1) being your first choice. You are not permitted to change regions nor add counties to your request form once your form has been returned to the Assessment Center. Please be advised you shall be disqualified from further consideration if you: Select more than one region Indicate counties outside of the region of choice Do not select any region Do not select any counties within the region of choice Please complete all information on the Authority for Release of Information. This form must be signed and notarized. Failure to complete the form will result in disqualification. Please answer all questions on the. Provide N/A in the appropriate space if not applicable. Applicants who do not currently hold a valid Ohio driver s license must contact the Bureau of Motor Vehicle who issued the license to obtain an abstract of your driving record for the previous ten years (if applicable). Applicants who have held a valid driver s license in more than one state, excluding Ohio, in the previous ten years must contact the Bureau of Motor Vehicle in all states who issued the license(s) and obtain an abstract of your driving record. Failure to forward the abstract driving record to the above address by the deadline date indicated in the instructions will result in disqualification unless prior authorization has been granted to submit information after the deadline date.

2 Day 3 Williams Defiance Paulding Van Wert Mercer Darke Preble Btl 1,2 Cin 1-6 Def 2 Def 1 Def 1 Def 1 Lim 2 Lim 2 Butler Hamilton Fulton Henry Putnam Allen Auglaize Shelby Mia 1 Def 2 Miami Montgomery Warren Hi 1 Def 2 Def 2 Lim 2 Day 1,2,3,4 Leb 1 & Btl 2 Clermont Rev. 08/11/06 Adult Parole Authority Regions & Units Lim 2 Lim 3 Lucas Wood Hancock Hardin Logan Champaign Clark 1 Day 3,4 Clark Greene Leb 1 Clinton Hi 1 Lim 1 Lim 1 Brown Tol 1,2, 3 Sen 1 Lim 1 Tol 1 Hi 1 Ottawa Sandusky Wyandot Union Madison Fayette Hi 1 Highland Scioto 1 Adams Union 1 Col 5 Sen 1 Sen 1 Sen 1 Sen 1 Seneca Union 1 Marion Crawford Delaware Franklin Pickaway Ross 1 Union 1 Col 5 Ross 1 Ross Scioto 1 Pike Msf 2 Col 1,2,3,4, 5,6,7,8, 9 Scioto Msf 3 Msf 3 Msf 4 Morrow Erie Huron Richland Col 5 Col 5 Msf 1,3,4 Knox Licking Fairfield Ath 2 Ross 1 Hocking Vinton Ross 1 Msf 2 Jackson Scioto 1 Lawrence Lorain Ashland Ath 2 Msf 3 Ath 1 Perry Gallia Ath 1 Ath 1 Ely 1-4 Msf 2 Msf 2 Msf 3 Medina Cuyahoga Wayne Holmes Coshocton Ath 2 Muskingum Athens Mar 1 Morgan Meigs Cle 1-13 Ely 4 Akr 1,2,3 Summit Tuscarawas Mar 1 Guernsey Mar 1 Mar 1 Can 1,2,3 NPh 1 PV 1 Noble PV 1 Lake Geauga PV1 Portage Stark NPh 1 Carrol Washington Harrison Mar 1 NPh 1 NPh 1 Ash 1 Adult Parole Authority Regions Cincinnati Region Cleveland Region Columbus Region Chillicothe Region Akron Region Lima Region Ashtabula Trumbull Mahoning Columbiana Belmont Monroe Yng 1,2 Yng 1,2, 3 Yng 3 NPh 1 Jefferson Mansfield Region

3 PAROLE OFFICER REGION REQUEST (Please Print) Name: You may select ONE Region. Once you have identified the Region, choose the counties within the Region where you would accept employment. Indicate the counties in order of preference with number one (1) being your first choice. Akron Region Ashtabula Geauga Mahoning Trumbull Belmont Harrison Portage Tuscarawas Carroll Jefferson Stark Columbiana Lake Summit Chillicothe Region Adams Gallia Monroe Scioto Athens Guernsey Morgan Vinton Brown Highland Muskingum Warren Butler Hocking Noble Washington Clermont Jackson Perry Clinton Lawrence Pike Fayette Meigs Ross Cincinnati Region Clark Hamilton Montgomery Greene Miami Preble Cleveland Region Cuyahoga Columbus Region Fairfield Licking Pickaway Franklin Madison Lima Region Allen Hancock Ottawa VanWert Auglaize Hardin Paulding Williams Champaign Henry Putnam Wood Darke Logan Sandusky Wyandot Defiance Lucas Seneca Fulton Mercer Shelby Mansfield Region Ashland Erie Lorain Richland Coshocton Holmes Marion Wayne Crawford Huron Medina Union Delaware Knox Morrow Signature: Date: Revised 11/2005

4 Ohio Department of Rehabilitation and Correction AUTHORITY FOR RELEASE OF INFORMATION Last Name: First Name: Middle Name: Social Security No.: Street Address: City: County: State: Zip Code: Place of Birth (county or city, state, country): Sex: Race: Date of Birth (m/d/y): I,, do hereby authorize a review and full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of the Ohio Department of Rehabilitation and Correction, whether the said records are of public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of the records of all educational institutions, courts, police agencies, present and previous employment to include pre-employment records, background reports, efficiency ratings, discipline records, termination records, complaints or grievances filed by or against me, and salary records. (In accordance with DRC Policy 34-PRO-07, Background Checks, Tables 1,2 &3) The intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation which may provide pertinent date for the Ohio Department of Rehabilitation and Correction to consider in determining my suitability for employment by that department. It is my specific intent to provide access to personal information, however personal or confidential it may appear to be, and the sources of information specifically identified herein. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the Ohio Department of Rehabilitation and Correction. I understand that all materials pertaining to this background investigation become the property of the Ohio Department of Rehabilitation and Correction and will not be returned to me. I hereby give permission and waive all provisions of company policy and law forbidding any school, court, police agency, employer, firm or person, from disclosing any knowledge or information they have concerning me. I agree to indemnify and hold harmless the person to whom this request is presented and his or her agents and employees, for and against all claims, damages, losses, and expenses, including reasonable attorney s fees, arising out of or by reason of complying with this request. (see ORC , Employer immunity as to job performance information disclosures, on the reverse of this form.) I further understand that in the event my application is disapproved, the sources of confidential information cannot be revealed to me. A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature. MUST BE SIGNED IN THE PRESENCE OF A NOTARY: Signature: Date: Subscribed and sworn before me this day of,. Notary: My commission expires: DRC1404 (Rev. 10/05) OPI Print Shop

5 Employer immunity as to job performance information disclosures. (A) As used in this section: (1) Employee means an individual currently or formerly employed by an employer. (2) Employer means the state, an political subdivision of the state, any person employing one or more individuals in this state, and any person directly or indirectly acting in the interest of the state, political subdivision, or such person. (3) Political subdivision and state have the same meanings as in section of the Revised Code. (B) An employer who is requested by an employee or a prospective employer of an employee to disclose to a prospective employer of that employee information pertaining to the job performance of that employee for the employer and who discloses the requested information to the prospective employer is not liable in damages in a civil action to that employee, the prospective employer, or any other employer is not liable in damages in a civil action to that employee, the prospective employer, or any other person for any harm sustained as approximate result of making the disclosure or of any information disclosed, unless the plaintiff in a civil action establishes, either or both of the following: (1) By a preponderance of the evidence that the employer disclosed particular information with the knowledge that it was false, with the deliberate intent to mislead the prospective employer or another person, in bad faith, or with malicious purpose; (2) By a preponderance of the evidence that the disclosure of particular information by the employer constitutes an unlawful discriminatory practice described in section , [ ], or [ ] of the Revised Code. (C) If the court finds that the verdict of the jury was in favor of the defendant, the court shall determine whether the lawsuit brought under division (B) of this section constituted frivolous conduct as defined in division (A) of section of the Revised Code. If the court finds by a preponderance of the evidence that the lawsuit constituted frivolous conduct, it may order the plaintiff to pay reasonable attorney s fees and court costs of the defendant. (D)(1) This section does not create a new cause of action or substantive legal right against an employer. (2) This section does not affect any immunities from civil liability or defenses established by another section of the Revised Code or available at common law to which an employer may be entitled under circumstances not covered by this section. HISTORY: 146 v H 44. Eff The provisions of 2 of HB 44 (146 v --) read as follows: SECTION 2. Section of the Revised Code, as enacted by this act, shall apply only to cause of action against employers, as defined in the section, for harm that allegedly arises from the disclosure of job performance information pertaining to an employee, as defined in that section, which occurs on or after the effective date of this act. With respect to causes of action against employers for harm that allegedly arose from a disclosure of job performance information pertaining to an employee prior to the effective date of this act, the liability or immunity from liability of an employer and the defenses available to an employer shall be determined as if section of the Revised Code has not been enacted.

6 DIVISION OF PAROLE AND COMMUNITY SERVICES Instructions The purpose of the is to assist the Division of Parole and Community Services in conducting a preliminary background investigation. Additionally, it will permit the Division to assess your qualifications for employment. Please read all instructions and questions on the form. Answer all questions accurately and completely. If a question does not apply to you, write NA (not applicable). If the space provided is insufficient, use a separate 8½ by 11 sheet and number answers to correspond with questions. Omissions of facts or false information will be grounds for rejection of employment or dismissal.

7 Division of Parole and Community Services PERSONAL 1. Your Name (Please print or type) Last: First: Middle: Other names (including nicknames) you have used or been known by: LEGAL 2. Have you ever been convicted of a felony or are you currently pending any felony charges? Yes No Charged with Convicted of Date of Conviction Sentence (e.g., jail or prison term, fine amount, probation, community service) 3. Have you ever been convicted of a misdemeanor or are you currently pending any misdemeanor charges? (For traffic violations only list DUI s and OMVI s) Yes No Charged with Convicted of Date of Conviction Sentence (e.g., jail or prison term, fine amount, probation, community service) 4. Have you had any criminal convictions sealed or expunged? Yes No Charged with Convicted of Date of Conviction Sentence (e.g., jail or prison term, fine amount, probation, community service) 5. Are you currently on probation with any city, county, or state law/other enforcement agency? Yes No Conviction Agency Date of Conviction Length of Probation 1

8 Division of Parole and Community Services MOTOR VEHICLE OPERATION An investigation of your driving history will be made through a record check. To expedite this procedure, please supply the following information. 6. Do you currently have a valid driver s license with full driving privileges? Yes No If No please explain: Driver s License Number: Expiration Date: State under which license was issued: Name under which license was granted: 7. Please list other states where you have been licensed to operate a motor vehicle. State: Dates: Name under which license was granted: State: Dates: Name under which license was granted: State: Dates: Name under which license was granted: State: Dates: Name under which license was granted: Applicants who do not currently hold a valid Ohio driver s license must contact the Bureau of Motor Vehicle who issued the license to obtain an abstract of your driving record for the previous ten years (if applicable). Applicants who have held a valid driver s license in more than one state, excluding Ohio, in the previous ten years must contact the Bureau of Motor Vehicle in all states who issued the license(s) and obtain an abstract of your driving record. Forward the information to: Ohio Corrections Assessment Center, ATTN: S. Pennington, P.O. Box 210, Orient, Ohio Failure to forward the abstract driving record from the state(s) indicated above by March 30, 2007 will result in disqualification unless prior authorization has been granted to submit information after the deadline date. Please contact Sherri Pennington at (614) Ext. 315 or Kim Sexton at (614) Ext. 316 for prior approval. 2

9 Division of Parole and Community Services MILITARY SERVICE 8. Have you ever served in the armed forces, National Guard, or military reserves? Yes No If Yes please supply the following information: Branch of Service: Service Number: Dates of Service (From [m/y] To [m/y]): Type of Discharge: 9. Have you ever been the subject of any judicial or non-judicial disciplinary action while in the military, National Guard, or military reserves? Yes No If Yes please give details (include branch of service, when, where, and circumstances): 10. Have you ever been fired or asked to resign from any place of employment? Yes No Dates of Employment Employer Reason for Termination 11. Have you ever been a full time, part time, or temporary employee for the State of Ohio? Yes No Dates of Employment Employer/Institution Reason for Termination 3

10 Division of Parole and Community Services EDUCATION 12. Have you completed a college degree? Yes No Please list the following: College/University Major Type of Degree (Associate, Bachelor, Master, Doctorate) Date Degree Was Attained 13. Have you completed a college internship program? Yes No Please list the following: Agency/Institution Dates of Internship (From/To) Job Duties CERTIFICATIONS 14. If you have obtained one of the following certifications, please complete the information. Certificates Issued by Certificate Number Expires Certified Marriage Counselor Cardiopulmonary Resuscitation (CPR) Certified Chemical Dependency Counselor (CCDC) Certified Fraud Examiner Emergency Medical Technician/First Responder Certification First Aid Certification OPOTA or DRC Firearms Instructor Certification Polygrapher Preventative Specialist Certification Ohio Certified Public Managers Program (OCPM) Sex Offender Certification State Tested Nurses Assistant/Aid (STNA) Certification 4

11 Division of Parole and Community Services LICENSURES 15. If you have obtained one of the following licensures, please complete the information. Licensure Issued by License Number Expires Licensed Independent Social Worker (LISW) Licensed Social Worker (LSW) Licensed Independent Chemical Dependency Counselor (LICDC) Licensed Chemical Dependency Counselor (LPC) Licensed Professional Clinical Counselor (LPCC) Licensed Attorney Licensed Practical Nurse (LPN) Registered Nurse (RN) I hereby certify that all statements made in the are true and complete. I understand that failure to disclose or misrepresentation of material facts may result in disqualification or dismissal. Print Full Name Signature Date 11/2006 5

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