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Home » Employee Abuse Registry (EAR) Removal Petition Form

Employee Abuse Registry (EAR) Removal Petition Form

Division of Health Improvement Employee Abuse Registry (EAR) Petition for Removal

Please provide all relevant information to demonstrate your rehabilitation. You may attach additional pages if you run out of space on this form. The Department may verify any and all information contained in this document.

Step 1 of 4

Petitioner’s Information:

Your Name:(Required)

First: MIddle: Last:

Name on Registry (if different than name above):

First: MIddle: Last:

Social Security Number:(Required)

Current Age:(Required)

Please enter a number from 1 to 120.

Date of Birth:(Required)

Date of Registry Placement:(Required)

Date of Petition:(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Your Email Address

Enter Email Confirm Email

Employment History

List ALL employment you have had AFTER your placement on the Registry. Use extra pages if necessary. Attach any letters of reference or recommendation related to your employment.

Current or Most Recent Employer’s Name:(Required)

Start date of Employment:(Required)

End date of Employment:(Required)

Your Position/Title:(Required)

Reason for Leaving:(Required)

Employer Contact Name and Position/Title:(Required)

Employer Contact Phone:(Required)

Employer Street Address(Required)

Street Address City State ZIP Code

Describe Job Duties:(Required)

Employment Information 2:

if applicable, list additional employment you have had AFTER your placement on the Registry.

Employer’s Name:

Start date of Employment:

End date of Employment:

Your Position/Title:

Reason for Leaving:

Employer Contact Name and Position/Title:

Employer Contact Phone:

Employer Street Address

Street Address City State ZIP Code

Describe Job Duties:

Employment History 3:

if applicable, list additional employment you have had AFTER your placement on the Registry.

Employer’s Name:

Start date of Employment:

End date of Employment:

Your Position/Title:

Reason for Leaving:

Employer Contact Name and Position/Title:

Employer Contact Phone:

Employer Street Address

Street Address City State ZIP Code

Describe Job Duties:

Community Service or Volunteer History:

List any, unpaid or volunteer experience you have had AFTER your placement on the Registry. Include community service, family care giving or other experience. Use extra pages if necessary. Attach any evidence of your experience and letters or recommendation related to your experience.

Name of Agency/Organization:

Phone Number:

Dates of Experience:

Position/Title/Role:

Reason for Leaving:

Address where experience occurred:

Street Address City State ZIP Code

Contact Name to Verify Experience:

Position/Relationship:

Contact Person Phone:

Describe Duties:

Upload Any Supporting Documentation:

Please upload any supporting documentation regarding your volunteer or community service. This could include certificates of completion, verified (signed) time logs, or other evidence of completion.

Max. file size: 512 MB.

Rehabilitation, Education or Other Training:

List any rehabilitation, education or training you have obtained AFTER placement on the Registry. Use extra pages if necessary. Attach a copy of any transcripts, diplomas, certificates or other evidence of successful completion.

Name of Person/School/Agency that provided class/training:

Name of Class/Training:

Date(s) of Class/Training:

Describe Content of Class/Training:

Upload Certificates, Transcripts, Diplomas, or any other supporting evidential documentation:

Max. file size: 512 MB.

Education/Training/Rehabilition 2:

Name of Person/School/Agency that provided class/training:

Name of Class/Training:

Date(s) of Class/Training:

Describe Content of Class/Training:

Upload Certificates, Transcripts, Diplomas, or any other supporting evidential documentation:

Max. file size: 512 MB.

Abuse, Neglect and Exploitation Specific Training

Please identify the courses, trainings, or classes you have participated in that directly address or relate to abuse, neglect and exploitation.

Name of Person/School/Agency that provided class/training:(Required)

Name of Class/Training:(Required)

Date(s) of Class/Training:(Required)

Describe Content of Class/Training:(Required)

Upload Certificates, Transcripts, Diplomas, or any other supporting evidential documentation:(Required)

Max. file size: 512 MB.

Petition Explanation

The review committee must be assured you will not abuse, neglect or exploit someone in your care again in order to remove your name from the registry. Explain how you have been rehabilitated following placement on the Registry so you can now safely care for others. Your explanation must demonstrate “Good Cause” why your name should be removed from the Registry. Show/explain to the review committee how you or your circumstances have changed. Provide any information you want the review committee to consider. You can include: how the circumstances that got you on the registry have changed; restitution you have made; any support groups you have attended; positive changes in your life; examples of your good character or reputation; anything else that shows you can be trusted to safely provide care to others again. Use extra pages if necessary. Attach any evidence you have to support your statements including letters of reference from others.

Explanation:(Required)

Additional Documentation:

Upload letters of reference or recommendation, evidence of character, or any additional information you wish to be considered in this review.