Life Skills Coach Application Total Homecare Solutions, LLC. #3109059 6730 Roosevelt Ave. Suite 200 Middletown, OH 45005 Contact: (513) 530 1179 Please fill out the below information to the best of your ability. Your Information : Name Your Address Information : Address line 1 Address line 2 https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 1/18
City Enter City... State Select State... Country USA Zip Enter Zip... Contact Information : Phone # Cell # Email General Questions https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 2/18
Which Office are you applying for: Butler County Office Montgomery County Office Miami County Office Date you can start: How did you hear about us? Word of Mouth Job Fair Direct Mailer e mail Indeed Craigs List Facebook Employee Job Center Newspaper Church Other Please list the Employee that referred you. Are you a US citizen or legally eligible to hold employment in USA? Yes No Are you at least 18 years old? Yes No Availability How many hours can you work each week? **THS pays OT for any hours worked above 40. https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 3/18
29 hours or less 40 Hrs per week 40 50 Hrs per week More than 50 Hrs per week What Shifts are you available for? Sunday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Monday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Tuesday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Wednesday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Thursday: https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 4/18
1ST SHIFT 2ND SHIFT 3RD SHIFT Friday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Saturday: 1ST SHIFT 2ND SHIFT 3RD SHIFT Employment Requirements Have you ever been arrested, charged as, or convicted as an adult for an offense that is not a traffic violation? Yes No If YES, please explain https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 5/18
** To work in this field, you MUST be able to answer "I Attest" to each of the Disqualifying Offense Tiers listed below. TIER 1 OFFENSES: Permanent exclusion from working with Individuals with disabilities. 1. R.C. 2903.01 Aggravated murder 2. R.C. 2903.02 Murder 3. R.C. 2903.03 Voluntary Manslaughter 4. R.C. 2903.11 Felonious Assault 5. R.C. 2903.15 Permitting Child Abuse 6. R.C. 2903.16 Failing to Provide for a Functionally Impaired Person 7. R.C. 2903.34 Patient Abuse; Neglect 8. R.C. 2903.341 Patient Endangerment 9. R.C. 2905.01 Kidnapping 10. R.C. 2905.02 Abduction 11. R.C. 2905.32 Human Trafficking 12. R.C. 2905.33 Unlawful Conduct with Respect to Documents 13. R.C. 2907.02 Rape 14. R.C. 2907.03 Sexual Battery 15. R.C. 290 7 M4 Unlawful Sexual Conduct with a Minor, Formerly Corruption of a Minor 16. R.C. 2907.05 Gross sexual imposition 17. R.C. 2907.06 Sexual imposition 18. R.C. 2907.07 Importuning https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 6/18
19. R.C. 2907.08 Voyeurism 20. R.C. 2907.12 Felonious Sexual Penetration 21. R.C. 2907.31 Disseminating Matter Harmful to Juveniles 22. R.C. 2907.32 Pandering Obscenity 23. R.C. 2907.321 Pandering Obscenity Involving a Minor 24. R.C. 2907.322 Pandering Sexually Oriented Matter Involving a Minor 25. R.C. 2907.323 Illegal use of Minor in Nudity Oriented Material or Performance 26. R.C. 2909.22 Soliciting/Providing Support for Act of Terrorism 27. R.C. 2909.23 Making Terrorist Threat 28. R.C. 2909.24 Terrorism 29. R.C. 2913.40 Medicaid Fraud 30. R.C. 2923.01 Conspiracy 31. R.C.2923.02 Attempt 32. R.C. 2923.03 Complicity when the underlying offense is any of the offenses or violations described in # s 1 thru 29;; 32. R.C. 2923.03 Complicity when the underlying offense is any of the offenses or violations described in # s 1 thru 29; 33. 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 or women, infants, and children program benefits); or 34. 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 described in sections1 to 32. I ATTEST THAT I HAVE NOT BEEN ARRESTED, CHARGED WITH, CONVICTED OF OR PLEAD GUILTY TO ANY OF THE TIER 1 DISQUALIFYING OFFENSES I attest I do not attest https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 7/18
TIER 2 OFFENSES: Cannot work with Individuals with disabilities for 10 years after being discharged from imprisonment, probation, and parole due to being convicted of one of the following offenses. 1. R.C. 2903.04 Involuntary Manslaughter 2. R.C. 2903.041 Reckless Homicide 3. R.C. 2905.04 Child Stealing as it existed prior to July 1, 1996 4. R.C. 2905.05 Criminal Child Enticement 5. R.C. 2905.11 Extortion 6. R.C. 2907.21 Compelling Prostitution 7. R.C. 2907.22 Promoting Prostitution 8. R.C. 2907.23 Enticement or Solicitation to Patronize a Prostitute, Procurement of a Prostitute for Another 9. R.C. 2909.02 Aggravated Arson 10. R.C. 2909.03 Arson 11. R.C. 2911.01 Aggravated Robbery 12. R.C. 2911.11 Aggravated Burglary 13. R.C. 2913.46 Illegal use of Supplemental Nutrition Assistance Program or Women, Infants, and children program benefits 14. R.C. 2913.48 Workers Compensation Fraud 15. R.C. 2913.49 Identity Fraud https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 8/18
16. R.C. 2917.02 Aggravated Riot 17. R.C. 2923.12 Carrying Concealed Weapon 18. R.C. 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; 19. R.C. 2923.123 Illegal conveyance, possession or control of deadly weapon or dangerous ordnance into courthouse. 20. R.C. 2923.13 Having Weapons while under Disability 21. R.C. 2923.161 Improperly discharging a firearm at or into a habitation or school 22. R.C. 2923.16 Discharge of firearm on or near prohibited premises 23. R.C. 2923.21 Improperly Furnishing Firearms to Minor 24. R.C. 2923.32 Engaging in Pattern Corrupt Activity 25. R.C. 2923.42 Participating in Criminal Gang; (x)cvi) 2925.02 (corrupting another with drugs) 26. R.C. 2925.03 Trafficking in Drugs 27. R.C. 2925.04 Illegal manufacture of drugs or cultivation of marijuana 28. R.C. 2925.041 Illegal assembly or possession of chemicals for the manufacturing of drugs 29. R.C. 3716.11 Placing harmful objects in food or confection 30. R.C. 2923.01 Conspiracy, 2923.02 Attempt, or 2923.03 Complicity when the underlying offense is any of the offenses or violations described in 1 to 30; or 31. A violation of an existing or former municipal ordinance or law of this, any other state, or the United States that is substantially equivalent to any of the offenses or violations described in 1 to 31. I ATTEST THAT I HAVE NOT BEEN ARRESTED, CHARGED WITH, CONVICTED OF OR PLEAD GUILTY TO ANY OF THE TIER 2 DISQUALIFYING OFFENSES I attest I do not attest TIER 3 OFFENSES: Cannot work with Individuals with disabilities for 7 years after being discharged from imprisonment, https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 9/18
probation, and parole due to being convicted of one of the following offenses. 1. R.C. 959.13 Cruelty to Animals 2. R.C. 959.131 Prohibitions Concerning Companion Animals 3. R.C. 2903.12 Aggravated Assault 4. R.C. 2903.21 Aggravated Menacing 5. R.C. 2903.211 Menacing by Stalking 6. R.C. 2905.12 Coercion 7. R.C. 2909.04 Disrupting Public Services 8. R.C. 2911.02 Robbery 9. R.C. 2911.12 Burglary 10. R.C. 2913.47 Insurance Fraud 11. R.C. 2917.1 Inciting to Violence 12. R.C. 2917.03 Riot 13. R.C. 2917.31 Inducing Panic 14. R.C. 2919.22 Endangering Children 15. R.C. 2919.25 Domestic Violence 16. R.C. 2921.03 Intimidation 17. R.C. 2921.11 Perjury https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 10/18
18. R.C. 2921.13 Falsification, Falsification in Theft Offense, Falsification to Purchase Firearm, or Falsification to Obtain a Concealed Handgun License 19. R.C. 2921.34 Escape 20. R.C. 2921.35 Aiding escape or resistance to lawful authority 21. R.C. 2921.36 Illegal Conveyance of Weapons, Drugs, or other Prohibited items onto grounds or institution 22. R.C. 2925.05 Funding of drug or marijuana trafficking 23. R.C. 2925.06 Illegal administration or distribution of anabolic steroids 24. R.C. 2925.24 Tampering with Drugs 25. R.C. 2927.12 Ethnic Intimidation 26. R.C. 2923.01 R.C. 2923.01 Conspiracy, 2923.02 Attempt, or 2923.03 Complicity when the underlying offense is any of the offenses or violations described in 1 to 25; or 27. A violation of an existing or former municipal ordinance or law of this state, any other States that is substantially equivalent to any of the offenses or violations described in 1 to 26. I ATTEST THAT I HAVE NOT BEEN ARRESTED, CHARGED WITH, CONVICTED OF OR PLEAD GUILTY TO ANY OF THE TIER 3 DISQUALIFYING OFFENSES I attest I do not attest TIER 4 OFFENSES: Cannot work with Individuals with disabilities for 5 years after being discharged from imprisonment, probation, and parole due to being convicted of one of the following offenses. https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 11/18
1. R.C. 2903.13 Assault 2. R.C. 2903.22 Menacing 3. R.C. 2907.09 Public Indecency 4. R.C. 2907.24 Soliciting after positive human immunodeficiency virus test 5. R.C. 2907.25 Prostitution 6. R.C. 2907.33 Deception to obtain matter harmful to juveniles 7. R.C. 2911.13 Breaking and Entering 8. R.C. 2913.02 Theft 9. R.C. 2913.03 Unauthorized use of a vehicle 10. R.C. 2913.04 Unauthorized use of property, computer, cable, or telecommunication property 11. R.C. 2913.05 Telecommunications Fraud 12. R.C. 2913.11 Passing bad checks 13. R.C. 2913.21 Misuse of credit cards 14. R.C. 2913.31 Forgery, forging identification cards 15. R.C. 2913.32 Criminal Simulation 16. R.C. 2913.41 Defrauding a rental agency or hostelry https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 12/18
17. R.C. 2913.42 Tampering with records 18. R.C. 2913.43 Securing writings by deception 19. R.C. 2913.44 Personating an Officer 20. R.C. 2913.441 Unlawful display of law enforcement emblem 21. R.C. 2913.45 Defrauding Creditors 22. R.C. 2913.51 Receiving Stolen Property 23. R.C. 2919.12 Unlawful Abortion 24. R.C. 2919.121 Unlawful Abortion upon minor 25. R.C. 2919.123 Unlawful distribution of an abortion inducing drug 26. R.C. 2919.23 Interference with Custody 27. R.C. 2919.24 Contributing to unruliness or delinquency of child 28. R.C. 2921.12 Tampering with Evidence 29. R.C. 2921.21 Compounding a Crime 30. R.C. 2921.24 Disclosure of Confidential Information 31. R.C. 2921.32 Obstructing Justice 41. R.C. 2925.56 Unlawful sale of pseudoephedrine product 42. R.C. 2923.01 R.C. 2923.01 Conspiracy, 2923.02 Attempt, or 2923.03 Complicity when the underlying offense is any of the offenses or violations described in 1 to 42; or 43. A violation of an existing or former municipal ordinance or law of this state, any other States that is substantially equivalent to any of the offenses or violations described in 1 to 42. https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 13/18
32. R.C. 2921.321 Assaulting/harassing police dog or horse/service animal 33. R.C. 2921.51 Impersonation of Peace Officer 34. R.C. 2925.09 Illegal administration, dispensing, distribution, manufacture, possession, selling, dangerous veterinary drug 35. R.C. 2925.11 Drug possession other than a minor drug possession offense 36. R.C. 2925.13 Permitting drug abuse 37. R.C. 2925.22 Deception to obtain dangerous drugs 38. R.C. 2925.23 Illegal processing of drug documents; mix 39. R.C. 2925.36 Illegal dispensing of drug samples 40. R.C. 2925.55 Unlawful purchase of pseudoephedrine product I ATTEST THAT I HAVE NOT BEEN ARRESTED, CHARGED WITH, CONVICTED OF OR PLEAD GUILTY TO ANY OF THE TIER 4 DISQUALIFYING OFFENSES I attest I do not attest Applicant Information County of Residence Butler County Champaign County Clark County Greene County Hamilton County Miami County Montgomery County Preble County https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 14/18
Shelby County Warren County Drivers License or ID Number Drivers License or ID expiration date Social Security Number 0 Date of Birth Education Do you have a High School Diploma or a GED? High School Diploma GED None A High School Diploma or GED is required and must be produced at time of interview. Institution Name https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 15/18
Institution Address Year Received References Please provide 2 references from your past work history. Reference 1: Company 1 Name: Person's Name: How should I contact them? Please enter in a Phone number, Cell Phone number or Email Address. Position in Company: https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 16/18
Reference 2: Company 2 Name: Person's Name: How should I contact them? Please enter in a Phone number, Cell Phone number or Email Address. Position in Company: Disclaimers I understand that I must wear all required personal protection equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination. (please enter your initials to confirm statement) I understand that I must report all accidents to my immediate supervisor and to Total Homecare Solutions NO MATTER HOW https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 17/18
SLIGHT (please enter your initials to confirm statement) I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT (please type your full name to apply your electronic signature) Submit 2016 HomeTrak (ver. 6.0.5891.20569) https://11379.hometrakcloud.com/htservices//inquiry/create/caregiver 18/18