County Board Certification Application Addendum Form - Ohio

This Ohio-specific printable "County Board Certification Application Addendum Form" is a part of the legal paperwork issued by the Ohio Department of Developmental Disabilities.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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County Board Certification
Application Addendum
(Page 1 of 6)
Rule 5123:2-2-02 of the Ohio Administrative Code
Background Investigations for Employment
Have you ever been convicted of any of the offenses listed in this application addendum, including any existing or former
municipal ordinance or law of this state, or any other state, or the United States that is substantially equivalent to the offenses
listed in this addendum?
___ Yes
___No
You must answer this question even if the record of your conviction(s) has been sealed or expunged by a court of law and
regardless of whether or not the conviction appears on a criminal background check. If you do not know if your conviction is
substantially equivalent to any of the offenses listed below, please provide the information required on the last page of this
form.
Information required in completing the application addendum: Please provide as much detail as possible, including a
person account of the nature of the offense, include the date, city, county and state where the conviction occurred and an
explanation of the circumstances leading up to the conviction; also include a description of the charge. If the conviction has
been sealed or expunged, also provide detailed information regarding the sealing or expungement and attach a copy of the
court journal entry. This information can be recorded in the box to the right of the offense and/or on the last page of this
form.
Disqualifying Offenses:
Tier 1 Disqualifying Offenses
2903.01 (aggravated murder)
2903.02 (murder)
2903.03 (voluntary manslaughter)
2903.11 (felonious assault)
2903.15 (permitting child abuse)
2903.16 (failing to provide for a functionally impaired person)
2903.34 (patient abuse and neglect)
2903.341 (patient endangerment)
2905.01 (kidnapping)
2905.02 (abduction)
2905.32 (human trafficking)
2905.33 (unlawful conduct with respect to documents)
2907.02 (rape)
2907.03 (sexual battery)
2907.04 (unlawful sexual conduct with a minor, formerly corruption of a
minor)
1
County Board Certification
Application Addendum
(Page 1 of 6)
Rule 5123:2-2-02 of the Ohio Administrative Code
Background Investigations for Employment
Have you ever been convicted of any of the offenses listed in this application addendum, including any existing or former
municipal ordinance or law of this state, or any other state, or the United States that is substantially equivalent to the offenses
listed in this addendum?
___ Yes
___No
You must answer this question even if the record of your conviction(s) has been sealed or expunged by a court of law and
regardless of whether or not the conviction appears on a criminal background check. If you do not know if your conviction is
substantially equivalent to any of the offenses listed below, please provide the information required on the last page of this
form.
Information required in completing the application addendum: Please provide as much detail as possible, including a
person account of the nature of the offense, include the date, city, county and state where the conviction occurred and an
explanation of the circumstances leading up to the conviction; also include a description of the charge. If the conviction has
been sealed or expunged, also provide detailed information regarding the sealing or expungement and attach a copy of the
court journal entry. This information can be recorded in the box to the right of the offense and/or on the last page of this
form.
Disqualifying Offenses:
Tier 1 Disqualifying Offenses
2903.01 (aggravated murder)
2903.02 (murder)
2903.03 (voluntary manslaughter)
2903.11 (felonious assault)
2903.15 (permitting child abuse)
2903.16 (failing to provide for a functionally impaired person)
2903.34 (patient abuse and neglect)
2903.341 (patient endangerment)
2905.01 (kidnapping)
2905.02 (abduction)
2905.32 (human trafficking)
2905.33 (unlawful conduct with respect to documents)
2907.02 (rape)
2907.03 (sexual battery)
2907.04 (unlawful sexual conduct with a minor, formerly corruption of a
minor)
1
2907.05 (gross sexual imposition)
2907.06 (sexual imposition)
2907.07 (importuning)
2907.08 (voyeurism)
2907.12 (felonious sexual penetration)
2907.31 (disseminating matter harmful to juveniles)
2907.32 (pandering obscenity)
2907.321 (pandering obscenity involving a minor)
2907.322 (pandering sexually oriented matter involving a minor)
2907.323 (illegal use of minor in nudity-oriented material or performance)
2909.22 (soliciting/providing support for act of terrorism)
2909.23 (making terrorist threat)
2909.24 (terrorism)
2913.40 (Medicaid fraud)
2923.01 (conspiracy) when the underlying offense is any of the offenses
or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or
violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or
violations on this list
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 [SNAP] or women, infants, and children [WIC]
program benefits).
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 on this list.
Tier 2 Disqualifying Offenses
2903.04 (involuntary manslaughter)
2903.041 (reckless homicide)
2905.04 (child stealing) as it existed prior to July 1, 1996
2905.05 (criminal child enticement)
2905.11 (extortion)
2907.21 (compelling prostitution)
2907.22 (promoting prostitution)
2907.23 (enticement or solicitation to patronize a prostitute, procurement
of a prostitute for another)
2909.02 (aggravated arson)
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2909.03 (arson)
2911.01 (aggravated robbery)
2911.11 (aggravated burglary)
2913.46 (illegal use of supplemental nutrition assistance program [SNAP]
or women, infants, and children [WIC] program benefits)
2913.48 (workers' compensation fraud)
2913.49 (identity fraud)
2917.02 (aggravated riot)
2923.01 (conspiracy) when the underlying offense is any of the offenses
or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or
violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses
or violations on this list
2923.12 (carrying concealed weapon)
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)
2923.123 (illegal conveyance, possession, or control of deadly weapon or
dangerous ordnance into courthouse)
2923.13 (having weapons while under disability)
2923.161 (improperly discharging a firearm at or into a habitation or
school)
2923.162 (discharge of firearm on or near prohibited premises)
2923.21 (improperly furnishing firearms to minor)
2923.32 (engaging in pattern of corrupt activity)
2923.42 (participating in criminal gang)
2925.02 (corrupting another with drugs)
2925.03 (trafficking in drugs)
2925.04 (illegal manufacture of drugs or cultivation of marihuana)
2925.041 (illegal assembly or possession of chemicals for the
manufacture of drugs)
3716.11 (placing harmful objects in food or confection)
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 on this list.
Tier 3 Disqualifying Offenses
959.13 (cruelty to animals)
959.131 (prohibitions concerning companion animals)
2903.12 (aggravated assault)
2903.21 (aggravated menacing)
2903.211 (menacing by stalking)
3
2905.12 (coercion)
2909.04 (disrupting public services)
2911.02 (robbery)
2911.12 (burglary)
2913.47 (insurance fraud)
2917.01 (inciting to violence)
2917.03 (riot)
2917.31 (inducing panic)
2919.22 (endangering children)
2919.25 (domestic violence)
2921.03 (intimidation)
2921.11 (perjury)
2921.13 (falsification, falsification in theft offense, falsification to purchase
firearm, or falsification to obtain a concealed handgun license)
2921.34 (escape)
2921.35 (aiding escape or resistance to lawful authority)
2921.36 (illegal conveyance of weapons, drugs, or other prohibited items
onto grounds of detention facility or institution)
2923.01 (conspiracy) when the underlying offense is any of the offenses
or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or
violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses
or violations on this list
2925.05 (funding of drug or marihuana trafficking)
2925.06 (illegal administration or distribution of anabolic steroids)
2925.24 (tampering with drugs)
2927.12 (ethnic intimidation)
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 on this list.
Tier 4 Disqualifying Offenses
2903.13 (assault)
2903.22 (menacing)
2907.09 (public indecency)
2907.24 (soliciting after positive human immunodeficiency virus test)
2907.25 (prostitution)
2907.33 (deception to obtain matter harmful to juveniles)
4
2911.13 (breaking and entering)
2913.02 (theft)
2913.03 (unauthorized use of a vehicle)
2913.04 (unauthorized use of property, computer, cable, or
telecommunication property)
2913.05 (telecommunications fraud)
2913.11 (passing bad checks)
2913.21 (misuse of credit cards)
2913.31 (forgery, forging identification cards)
2913.32 (criminal simulation)
2913.41 (defrauding a rental agency or hostelry)
2913.42 (tampering with records)
2913.43 (securing writings by deception)
2913.44 (personating an officer)
2913.441 (unlawful display of law enforcement emblem)
2913.45 (defrauding creditors)
2913.51 (receiving stolen property)
2919.12 (unlawful abortion)
2919.121 (unlawful abortion upon minor)
2919.123 (unlawful distribution of an abortion-inducing drug)
2919.23 (interference with custody)
2919.24 (contributing to unruliness or delinquency of child)
2921.12 (tampering with evidence)
2921.21 (compounding a crime)
2921.24 (disclosure of confidential information)
2921.32 (obstructing justice)
2921.321 (assaulting/harassing police dog or horse/service animal)
2921.51 (impersonation of peace officer)
2923.01 (conspiracy) when the underlying offense is any of the offenses
or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or
violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses
or violations on this list
2925.09 (illegal administration, dispensing, distribution, manufacture,
possession, selling, or using any dangerous veterinary drug)
2925.11 (drug possession other than a minor drug possession offense)
2925.13 (permitting drug abuse)
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