Application for Employment

Thank you for your interest in the Clermont County Board of Developmental Disabilities. The Board provides a trauma-informed approach with a broad range of services to children and adults with developmental disabilities who live in Clermont County. These services are provided at several locations throughout the county.

All positions require a minimum of a completed high school diploma or GED and the minimum age for employment is 18. You must meet the minimum qualifications for the position and apply for a specific position that is vacant to be considered as a valid applicant.

Applications missing information will be discarded. All applications will be considered active up to six (6) months after the filing of the application. The application is retained in the personnel file, if hired.

Members of the immediate families of the seven-member Clermont County Board of Developmental Disabilities or the Board of County Commissioners may not be hired to work for the Clermont County Board of Developmental Disabilities. Applicants hired by the Board are not permitted to work in Clermont County as independent providers of persons receiving services from the Board.

HIRING PROCESS

Completed applications are received and reviewed by the Human Resources Department. If applicable, Human Resources will send a copy to the department manager/director, based upon the applicant’s qualifications and ability to perform the essential job functions of the position applied for, with or without reasonable accommodation.

There is no requirement to interview all applicants. Following the initial interview, applicants may be recommended for additional interviews with other staff, supervisors, and/or the Superintendent.

All offers of employment may be extended only by the Superintendent. All offers of employment are contingent upon successful completion of a job-related medical examination and drug test, a criminal history background check (required by Ohio Administrative Code 5123:2-02), and a driving abstract which is required for each applicant who might transport individuals or operate agency vehicles for any purpose.

Certification / Licensure / Registration

Positions that involve providing services to individuals or supervising staff that provide services to individuals require certification, license, and/or registration. You may be required to complete seminars or college courses at your own expense to obtain a certification or license. You are required to provide a copy of any certificate, license, and/or registration that you currently hold. It is also the expectation of the Board that each employee will receive training in trauma-informed care.

Position Applied For

(If blank, application will not be valid.)

Full Legal Name

Other Names Used

Mailing Address

Address Line 1

City

State

Physical Address of Your Residence

Address Line 1

City

State

Phone

Alternate Phone

(All applicants/employees are required to have a phone number where messages can be left and promptly received.)

(Email is required for employees.)

Are you at least 18 years of age?

Did you graduate from high school and/or complete a G.E.D.?

Can you perform the essential functions of the position for which you applied, with or without reasonable accommodation?

Date available to start work / Days and Hours Available

Date

Time

Have you worked for this agency before?

What was your reason for leaving?

How did you learn of this vacancy?

If from an employee, who?

Background Investigation Notice

```

Pursuant to Ohio Administrative Code (OAC) Section 5123:2-02, the Clermont County Board of Developmental Disabilities is required to conduct background investigations for purposes of employment.

Please note that per 5123:2-02, there are several tiers of disqualifying offenses with corresponding time periods that preclude an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation.

For more information, please review OAC 5123:2-02.

```

EDUCATION

Proof of High School Diploma or GED is required for employment.

High School (Complete Name and Address)

College (Complete Name and Address)

Post Graduate (Complete Name and Address)

Business or Trade (Complete Name and Address)

GED Certificate Obtained Through & Date Received

***Must provide official Diploma or GED certificate upon hire.

** Must submit official transcripts for college and post-graduate education upon hire.

CERTIFICATION / LICENSURE / REGISTRATION

For many positions state certification, license, or registration requirements MUST be met.

Do you have a current certification/license from Ohio Department of Education and Workforce?

Do you have a current registration/license from Ohio Department of Developmental Disabilities?

Do you have any other licenses or registrations that qualify you?

Types of Certificate/License/Registration

Authorizing Board or Agency

Expiration Dates

Types of Certificate/License/Registration

Authorizing Board or Agency

Expiration Dates

Types of Certificate/License/Registration

Authorizing Board or Agency

Expiration Dates

DRIVER’S LICENSE

Do you have a valid driver’s license?

WORK EXPERIENCE AND EMPLOYMENT HISTORY

You must include all previous jobs. Resume may NOT be substituted.

Name of Employer:

Phone

Address

Address Line 1

City

State

Zip Code

Name & Title of Supervisor

May we contact?

Your Job Title

Dates of employment

Starting Date

Ending Date

Status

Full Time
Part Time
Substitute

Salary Starting

Your Responsibilities

Salary Ending

Reason for Leaving

Name of Employer:

Phone

Address

Address Line 1

City

State

Zip Code

Name & Title of Supervisor

May we contact?

Your Job Title

Dates of employment

Starting Date

Ending Date

Status

Full Time
Part Time
Substitute

Salary Starting

Your Responsibilities

Salary Ending

Reason for Leaving

Name of Employer:

Phone

Address

Address Line 1

City

State

Zip Code

Name & Title of Supervisor

May we contact?

Your Job Title

Dates of employment

Starting Date

Ending Date

Status

Full Time
Part Time
Substitute

Salary Starting

Your Responsibilities

Salary Ending

Reason for Leaving

Name of Employer:

Phone

Address

Address Line 1

City

State

Zip Code

Name & Title of Supervisor

May we contact?

Your Job Title

Dates of employment

Starting Date

Ending Date

Status

Full Time
Part Time
Substitute

Salary Starting

Your Responsibilities

Salary Ending

Reason for Leaving

If you do not want us to contact a previous employer, indicate which one(s) and why

PROFESSIONAL WORK REFERENCES

List three work-related references, current or previous supervisors who this agency has permission to contact. Provide phone numbers.

Name

Occupation

Address

No. Street City State Zip Code

Telephone No

Name

Occupation

Address

No. Street City State Zip Code

Telephone No

Name

Occupation

Address

No. Street City State Zip Code

Telephone No

ADDITIONAL INFORMATION

Please summarize other experiences, skills or qualifications which you feel would qualify you for the position(s) for which you have applied.

How did you learn of the position(s) you applied for?

APPLICANT'S AGREEMENT

Read Before Signing

I will take courses to obtain the required certification/license of the position. I understand that these may or may not be college courses, and I may be responsible for paying for all classes/seminars required to obtain and maintain my certification/license.

I have read all sections of this application and certify that all the statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that the discovery of any false information provided or any relevant information omitted (no matter when discovered) may result in the refusal to hire me or the termination of my employment, at the discretion of the Superintendent. According to the Ohio Revised Code, I also understand that I must report any charges against me, convictions of, or guilty pleas to any disqualifying offenses to the Superintendent, within 14 (fourteen) days of charges, convictions, or guilty pleas. Failure to report may lead to disciplinary action up to and including termination. If hired, this requirement remains in effect the entire duration of my employment.

I authorize and instruct the Board to make whatever inquiries it considers necessary of any person or organization, which is not a consumer reporting agency, to verify any of the information I have provided in this application and to determine my qualifications and abilities. In exchange for the Board's agreement to receive, process and consider my application for employment, I hereby release the Board of any and all claims and causes of action arising out of the Board's efforts to verify the information I have provided in this application and/or its determination of my qualifications and abilities.

I am legally permitted to work in the United States.

I agree that any claim or lawsuit relating to my service with the Clermont County Board of Developmental Disabilities or any of its subsidiaries must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

Applicant's Signature:

Clear Signature

Date

The Clermont County Board of Developmental Disabilities Services is an Equal Opportunity Employer and will not discriminate or deny employment on the basis of race, color, religion, sex (to include gender identity or expression and sexual orientation), national origin, disability, age, pregnancy, familial status, ancestry, genetic information or military/veteran status.

NOTICE TO APPLICANTS

DRUG SCREENING:
The Clermont County Board of Developmental Disabilities is committed to maintaining a drug-free workplace. For that reason, it is our Agency policy to make all offers of employment expressly conditioned upon passing a drug-screening test. That means that if you are offered a job and do not pass the drug-screening test or refuse to take the test, the offer of employment will be withdrawn.

MEDICAL EXAM:
Job applicants may be required to undergo a medical examination prior to hire, and are required to agree in writing to permit such tests and examinations and the agency’s use of their results. Those job applicants who fail such tests and examinations will not be offered employment.

BACKGROUND CHECK
Pursuant to Ohio Administrative Code Section 5123-2-02, the Clermont County Board of Developmental Disabilities is required to conduct background investigations for purposes of employment. Please note that per Ohio Administrative Code 5123-2-02, there are several tiers of disqualifying offenses with corresponding time periods that disqualify an applicant from being employed with this agency. Therefore, all applicants under final consideration will be required to submit to a background check through the Bureau of Criminal Identification and Investigation.

For more information, please review OAC 5123-2-02.

Your signature verifies that you understand that all prospective employees must pass a drug test and medical examination prior to being hired. Your signature below verifies that you understand the requirement to conduct a background check following job offers and the disqualifying offenses that prevent an applicant from being employed with this agency.

Please Print Name

Applicant's Signature:

Clear Signature

Date

This form must accompany all applications for employment with Clermont County Board of Developmental Disabilities.

AFFIRMATIVE ACTION/EQUAL EMPLOYMENT OPPORTUNITY DATA SHEET

In compliance with Federal and State Equal Employment Opportunity laws, the Clermont County Board of Developmental Disabilities is required to collect and report data on all applicants/employees. The responses given will be held confidential and separate from the submitted employment application. You are not required to complete this form; however, we would appreciate your answers to the following:

Name (Voluntary):

First

Middle

Last

Address

Address Line 1

City

State

Zip Code

ETHNIC CATEGORY (check one):

Hispanic or Latino — A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) — A person having origins in any of the original peoples of Europe, Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) — A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) — A person having origins in Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) — A person having origins in Far East, Southeast Asia, or Indian Subcontinent (e.g., Pakistan, India, China, Japan, etc.).
American Indian or Alaska Native (Not Hispanic or Latino) — A person having origins in North and South America (including Central America) and maintaining tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) — A person identifying with more than one of the above categories.

Two or More Races (Not Hispanic or Latino) — A person identifying with more than one of the above categories.

A Qualified Disabled Individual (Has a physical or mental impairment substantially limiting major life activities, or record of such impairment, or regarded as having such impairment, and is qualified to perform the job with reasonable accommodation)
A Qualified Disabled Veteran (Entitled to disability compensation rated at 30% or more, or discharged due to service-connected disability, and qualified to perform job with accommodation)
A Vietnam Era Veteran (Served more than 180 days between August 5, 1964 and May 7, 1975 with other than dishonorable discharge, OR released for service-connected disability, OR discharged within 48 months prior to violation of applicable act/regulation)