Form Jfs 01328 - Statement Of Nonconviction For Child Care Centers And Type A Homes
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2Ohio Department of Job and Family Services
STATEMENT OF NONCONVICTION FOR CHILD CARE CENTERS AND TYPE A HOMES
This statement must be signed upon hire and annually thereafter by every: individual owner, administrator, employee,
second adult in a child care center or type A home and all persons 18 years of age and older who reside in a type A
home. This statement must be kept on file at the center or home.
Date of Hire
Name (please print or type)
I hereby attest that I have never been convicted of or pleaded guilty to crimes set forth in divisions (A)(8) or
(A)(9) of section 109.572 or division (A)(1) of 5104.09 of the Revised Code and that no child has been removed
from my home as described in section 2151.353 of the Revised Code.
I have had a child removed from my home as described in section 2151.353 of the Revised Code.
I have been convicted of a crime included in divisions (A)(8) or (A)(9) of section 109.572 or division (A)(1) of
5104.09 of the Revised Code.
Date
Signature of Person Completing Form
Street Address
City
State
Zip Code
Telephone Number
I have reviewed the rehabilitation requirements of rule 5101:2-12-26 or 5101:2-13-26 of the Administrative Code,
and determined that the employee meets the rehabilitation requirements. I have attached a completed copy of
the JFS 01206 and the documents to verify how these requirements have been met.
This section requires a signature only if t he employee is rehabilitated.
Date
Administrator's Signature (+)
Note: Anyone who withholds information from, or falsifies information on this statement is guilty of falsification, a misdemeanor of the first degree. If the
offender is an owner of a center or a licensee of a type A home, a type B home provider, or an in home aide, the conviction constitutes grounds for
denial, revocation, or refusal to renew a child care license application or child care certification. If the offender is an employee of a center or type A
home, or is a person eighteen years of age or older who resides in a type A or type B home or is an emergency or substitute caregiver, and if the owner
or licensee had knowledge of, and acquiesced in the commission of the offense, the conviction constitutes grounds for denial, revocation, or refusal to
renew a child care license application or child care certification.
Note: effective June 1, 2008 all civilian background checks must be submitted electronically through use of
WebCheck or other approved methods. More information can be found at:
.
▼
CENTERS AND TYPE A HOMES
The administrator is required to sign and date below verifying that fingerprints have been electronically
submitted to the Ohio Bureau of Criminal Identification and Investigation (BCII), or mailed if electronic
processing exemption criteria are met.
A criminal records check for the above named individual was requested on (date)
Ohio BCII records check
Federal Bureau of Investigation (FBI) records check (please check)
Date
Signature of Administrator(+)
▼
TYPE A HOMES ONLY
The licensee of a type A home must sign the following statement: I hereby attest that no one who resides in my home
and who is under eighteen years of age has been adjudicated a delinquent child for committing a violation of any offense
listed in divisions (A)(8) or (A)(9) of section 109.572 or division (A)(1) of 5104.09 of the Revised Code.
Date
Signature
▼
TO BE SIGNED BY THE ADMINISTRATOR
I have reviewed the results of this persons criminal records check on the following dates:
Ohio BCII
records check,
FBI records check. Section 5104.012 (A)(2) of the Revised Code requires the results
of these records checks to be reviewed and approved by the administrator prior to the employee having sole responsibility
for children.
Date
Signature of Administrator(++)
(+)(++) Administrators need to sign this section only when a new BCII or FBI criminal records check is requested (+) or completed. (++)
This is a prescribed form which must be used to meet the requirements of rules 5101:2-12-26 and 5101:2-13-26 of the Administrative Code.
JFS 01328 (Rev. 7/2010)
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