Forms & Policy

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Consumer Forms

 Annual Physical Form (PDF)

Appointment Tracking Sheet (PDF)

Authorization for Release of Health Information (PDF)

Authorization To Release Information (PDF)

Bar Codes (PDF)

Change of Personal Information (PDF)

Client Biography (PDF)

Client Record (PDF)

Consumer Consent Discard Form (PDF)

Dental Appointment (PDF)

Emergency Procedure (PDF)

Eye Examination Report (PDF)

Face Sheet (PDF)

Family Medical History (PDF)

Fire Safety Inservice (PDF)

Fire Safety Inspection (PDF)

General Med Pass Procedure in QuickMar (PDF)

Habilitation Plan Documentation (PDF)

Hearing Evaluation Form (PDF)

Household Checklist (PDF)

Individual Specific Training (PDF)

Individual Worksheet (PDF)

Interdisciplinary Medical Procedure Sign-Off Sheet (PDF)

Inventory Guideline (PDF)

Inventory Record (PDF)

IP Meeting (PDF)

Medical Appointment Form (PDF)

Medication Authorization – Montgomery County Board (PDF)

Medication Consent Form – Psychotropic Medication (PDF)

Medication Discharge (PDF)

Medication Disposal Log (PDF)

Medication Drop-Off (PDF)

Medication Error In-Service Form (PDF)

Medication Tracking Chart (PDF)

Menstrual Record Chart (PDF

MR/DD Bill of Rights (PDF)

New Client Information (PDF)

New Client Information- Day Hab & NMT (PDF)

Non-Staff Medication Administration Record (PDF)

Nurses Medication Notes/Blank MAR Form (PDF)

Ohio Developmental Disability Profile (PDF)

PRN List (PDF)

Program Record (PDF)

Release of Information ( For Annual Packet, Fillable-Online)

Release of Information (For Annual Packet, PDF)

Release of Information for Specific Item Only (Fillable-Online)

Seizure Record (PDF)

Seizure Record Chart (PDF)

Severe Weather Drill (PDF)

Shared Food Receipts Tracking – Non-Licensed Only (PDF)

Skills Assessment (PDF)

Staff Area Consent (PDF)

Statement Consent for Delegation (PDF)

Statement of Understanding (PDF)

Test or Procedure Record (PDF)

UI/MUI Report (PDF)

Unanticipated Hospitalization MUI Form (PDF)

Weather Safety Inservice (PDF)

Yearly Weight Record (PDF)

Administrative Forms

Admission Transfer Discharge Checklist (PDF)

Bar Code Sheet – Health Related Activities (PDF)

Bar Code Sheet – Staff (PDF)

Blank Cash Ledger (Excel)

Calendar (PDF)

Cash Ledger (PDF)

Chard Snyder FSA Reimbursement Form (PDF)

Client Budget Forms (PDF)

Compliance: Transportation Waiver, No Insurance (Fillable-Online)

Compliance: Transportation Waiver, Non-Driver (Fillable-Online)

Day Hab Bus Checklist (PDF)

Direct Deposit Form (PDF)

Director’s Home Review (PDF)

Educational Allowance Reimbursement (PDF)

Educational Assistance Program (Safe Haven Employees Only) (Formstack)

Employee Personal Information Change (PDF)

Employee Program Training (PDF)

Expense Reimbursement Form (PDF)

Finance Sheet (PDF)

Finder’s Fee Request (PDF)

First Report of Injury, Occupational Disease or Death (PDF)

Food Stamp Chart (PDF)

Form Summary Report (PDF)

FSA Claim Reimbursement Form (PDF)

Health & Welfare Alerts (PDF)

In-Home Meal Count for Staff (PDF)

Incidental Expenses (PDF)

Inservice Attendance Verification (PDF)

Inservice Request Form (PDF)

ISP Tally Sheet (PDF)

ISP Training Signature Sheet (PDF)

Job Posting Request (PDF)

Master Signature Log (PDF)

Med Class Application (PDF)

Med Admin Skills Checklist (PDF)

Program/Person Specific Training (PDF)

Personnel Action Form (PAF) (Online-Fillable)

Personal Mileage Report (PDF)

Phone Call Documentation (PDF)

Planned Hour Donation Form (PDF)

Power of Attorney (PDF)

Receipts (PDF)

Request for Paid Time Off (PDF)

Residential Respite (PDF)

Residential Specialist Short-Term Training (PDF)

Schedule For the Week (PDF)

Search Procedures & Checklist (PDF)

Shared Food Receipts Tracking – Non-Licensed Only (PDF)

Staff Activity Cost Summary (PDF)

Staff Exchange of Information (PDF)

Staff Schedules (PDF)

Time Sheet (PDF)

Transportation Template  (Excel)

Van Checklist – Mileage (PDF)

Vehicle Accident Reporting (PDF)

Vehicle Inspection Log (PDF)

Verbal Warning (PDF)

Volunteer Application (PDF)

Waiver Mileage (PDF)

Written Corrective Action (PDF)

Program Policies & Procedures
Personnel Policies & Procedures

COVID-19 Policy 5-4-20

Full Personnel Policy Listing

Personnel Policies Table of Contents

Policy 1: Purpose of Personnel Policies and Procedures

Policy 2-A: Equal Employment Opportunity – Fair Employment Practices

Policy 2-B: Equal Opportunity – Sexual Harassment

Policy 2-C: Equal Opportunity – Immigration and Control Act

Policy 2-D: Equal Opportunity – Resolving Employment and Program Participant Discrimination Complaints

Policy 3: Employee Selection & Hiring Procedures

Policy 4: Employee Classifications

Policy 5: Employment Relations Policy Statement

Policy 6: Wage and Salary Administration

Policy 7: Attendance & Punctuality

Policy 8: Agency Vehicle Driving Standards

Policy 9: Protocol – Telephone/Smoking/Personnel Records

Policy 10: Drugs & Alcohol

Policy 11: Other Employment

Policy 12: Conflict of Interest

Policy 13: Standards of Conduct – Performance Improvement Process

Policy 13-A: Standards of Conduct – Breaches of Employee Obligations (Trust)

Policy 14: Open Door Resolution of Issues, Complaints or Suggestions

Policy 15: Insured Employee Benefits

Policy 16: Unplanned Paid Leave

Policy 17: Leaves of Absence

Policy 18: Bereavement

Policy 18-A: Civic Duty

Policy 19: Vacation

Policy 20: Holidays

Policy 21: Training & Development

Policy 21-A: Tuition Reimbursement

Policy 22: Exiting Employees

Policy 23: Weekly Disability Income

Policy 24: Telephone Use

Policy 25: Fraternization

Policy 26: Conditional Employee Requirements

Policy 27: Safety

Policy 28: Information Systems

Policy 29: Requests for Employee References

Policy 30: Gift Giving

Policy 31: Workplace Violence

Policy 32: “No Weapons” 

Policy 33: Pager Delegation

Policy 34: Transfer Policy

Policy 35: Standards of Grooming & Dress

Policy 37: Statements to the News Media

Policy 38: Management Structure and Authority

Policy 39: Search Policy