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, Parole Officer Background Questionnaire, 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 43146-0210
• 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:
¾ Select more than one region
¾ Indicate counties outside of the region of choice
¾ Do not select any region
¾ 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 Parole Officer Background Questionnaire. Provide N/A in the appropriate space if not applicable.
¾ 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).
¾ 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.
Adult Parole Authority Regions
Cincinnati Region Cleveland Region Columbus Region Chillicothe Region Akron Region Lima Region Mansfield Region
Williams Fulton Lucas
Ottawa Defiance
Henry Wood Sandusky Erie
Lorain
Cuyahoga
Lake
Ashtabula Geauga
Trumbull
Mahoning Portage
Medina Huron
Seneca Hancock
Putnam Paulding
Van Wert Allen
Hardin
Wyandot Crawford
Richland Wayne Stark
Columbiana Carrol
Tuscarawas Holmes
Knox Morrow
Marion Auglaize
Mercer
Darke
Shelby Logan
Union Delaware
Franklin
Coshocton Harrison
Guernsey Licking
Muskingum Belmont
Monroe Noble
Morgan Perry
Fairfield Pickaway
Washington Athens
Meigs Hocking
Vinton
Gallia Jackson
Lawrence Scioto
Pike Ross Madison Champaign
Miami
Fayette Greene
Montgomery Preble
Butler Warren
Clinton
Highland
Adams Brown
Clermont Hamilton
Clark
Ashland
Summit
Jefferson
Scioto 1 Ath 1 Ross 1 Scioto 1
Ross 1
Ross 1 Ross 1 Hi 1
Leb 1
Hi 1
Scioto 1 Hi 1
Hi 1 Leb 1 & Btl 2 Btl 1,2
Cin 1-6 Day 3
Day 3,4 Clark 1 Mia 1
Col 5
Union 1 Union 1
Col 5
Col 5 Col 5
Ath 2 Ath 2 Ath 2
Ath 2 Mar 1 NPh 1
Mar 1 Mar 1
Mar 1
Ath 1
Ath 1
Mar 1 Msf 2
Msf 2 Msf 3
Akr 1,2,3
Can 1,2,3
NPh 1
NPh 1
NPh 1
NPh 1 Yng 1,2, 3 PV1
Ash 1
PV 1 PV 1 Cle 1-13
Ely 1-4
Msf 3
Msf 2 Msf 4 Union 1
Msf 2 Msf 3
Msf 3 Sen 1
Sen 1
Sen 1 Lim 3
Def 1
Sen 1 Tol 1
Sen 1 Tol 1,2, 3
Def 2 Def 2
Def 2 Def 1
Def 1
Def 2
Msf 1,3,4
Col 1,2,3,4, 5,6,7,8, 9 Lim 2
Lim 2
Lim 2 Lim 2
Lim 1
Lim 1
Lim 1
Day 1,2,3,4
Yng 1,2
Ely 4
Yng 3
Adult Parole Authority Regions & Units
Rev. 08/11/06
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
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 con- fidential 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, aris- ing out of or by reason of complying with this request. (see ORC 4113.71, Employer immunity as to job per- formance information disclosures, on the reverse of this form.) I further understand that in the event my appli- cation 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) O P I P r i n t S h o p
§ 4113.71
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 2744.01 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 4112.02, 4112.021 [4112.02.1], or [4112.02.2] 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 2323.51 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 7-3-96.
The provisions of § 2 of HB 44 (146 v --) read as follows:
SECTION 2. Section 4113.71 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 4113.71 of the Revised Code has not been enacted.
DIVISION OF PAROLE AND COMMUNITY SERVICES Parole Officer Background Questionnaire
Instructions
The purpose of the Parole Officer Background Questionnaire 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 Parole Officer Background Questionnaire
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.
Division of Parole and Community Services Parole Officer Background Questionnaire
1
1. Your Name (Please print or type)
Last: First: Middle:
Other names (including nicknames) you have used or been known by:
2. Have you ever been convicted of a felony or are you currently pending any felony charges?
Yes No
If “Yes” please list the following:
Charged with Convicted of Date of Conviction
Location (City & State)
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 If “Yes” please list the following:
Charged with Convicted of Date of Conviction
Location (City & State)
Sentence (e.g., jail or prison term, fine amount, probation, community service)
4. Have you had any criminal convictions sealed or expunged? Yes No If “Yes” please list the following:
Charged with Convicted of Date of
Conviction Location
(City & State) 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
If “Yes” please list the following:
Conviction Agency Date of
Conviction Location
(City & State) Length of Probation
PERSONAL
LEGAL
Division of Parole and Community Services Parole Officer Background Questionnaire
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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:
If “Yes” please list the following:
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 43146. 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) 877-2300 Ext.
315 or Kim Sexton at (614) 877-2300 Ext. 316 for prior approval.
MOTOR VEHICLE OPERATION
Division of Parole and Community Services Parole Officer Background Questionnaire
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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 If “Yes” please list the following:
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
If “Yes” please list the following:
Dates of
Employment Employer/Institution Reason for Termination
MILITARY SERVICE
Division of Parole and Community Services Parole Officer Background Questionnaire
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12. Have you completed a college degree? Yes No Please list the following:
College/University Location
(City & State) 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 Location
(City & State) Dates of Internship
(From/To) Job Duties
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
EDUCATION
CERTIFICATIONS
Division of Parole and Community Services Parole Officer Background Questionnaire
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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 Parole Officer Background Questionnaire 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
