At which location are you seeking employment? *Rolling Hills Care CenterCimarron Pointe Care CenterSequoyah Point Living CenterShawn Manor Nursing HomeSand Springs Nursing and RehabPosition applied for *Are you related by blood or marriage, living in the same residence, or in a dating relationship with any current employee or staff member, of the same or opposite sex?YesNoTo whom?PositionWhat is the nature of the relationship?Have you ever been employed by any of the Triacle Homes?YesNoAt which location? *Rolling Hills Care CenterCimarron Pointe Care CenterSequoyah Point Living CenterShawn Manor Nursing HomeSand Springs Nursing and RehabODH Form 805 Uniform Employment Application for Nurse Aide Staff This form is to be used by employers as the only employment application for hiring nurse aide staff in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care facilities, hospice programs, adult day care centers, and home care agencies as mandated by Title 63 O.S. § 1-1950.4, Uniform Employment Application for Nurse Aide Staff- Purpose - Training. The content of this form shall not be altered. Employer Instructions Provide this form to all applicants seeking employment as a nurse aide. The form may be duplicated as needed.Instruct the applicant to complete each section of this form.Personal InformationEmployment DesiredU.S. Military RecordPrior Work HistoryEducational BackgroundCertificationReferencesBackground InformationApplicant's Certification and AgreementPrevious CNA Training: If the applicant will require nurse aide training, instruct to complete section 10 on page 4. NOTE: If the facility has an approved nurse aide temporary emergency waiver, the applicant must be trained and certified within four (4) months of hire date. Category: List any CNA training received in the past by type of training: Long Term Care Aide (LTCA), Home Health Aide (HHA), Adult Day Care Aide (ADCA), Residential Care Aide (RCA), and Developmentally Disabled Direct Care Aide (DDDCA).Program Name: List the title of the training program where the training was received.Training Days: List the number of days of training completed for each category.Important Information for the Job Applicant Instruct applicant to read and initial in the gray 'NOTICE' box on page 5, then sign and date certifying the application is true and complete. Criminal Arrest Check Instruct the applicant to read and complete the 'Criminal Arrest Check List' section on page 5. Obtain the applicant's signature and date in the designated spaces.Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1(C) states Oklahoma State:§63-1-1950.1. Definitions - Criminal arrest check on certain persons offered employment -Exemptions. C. 1. If the results of a criminal history background check reveal that the subject person has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, the employer shall not hire or contract with the person: abuse, neglect, or financial exploitation of any person entrusted to the care or possession of such personrape, incest, or sodomychild abusemurder or attempted murdermanslaughterkidnappingaggravated assault and batteryassault and battery with a dangerous weapon, orarson in the first degree. 2. If less than seven (7) years have elapsed since the completion of sentence, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses. in any state or federal jurisdiction, the employer shall not hire or contract with the person: assaultbatteryindecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offenderpanderingburglary in the first or second degreerobbery in the first or second degreerobbery or attempted robbery with a dangerous weapon, or imitation firearmarson in the second degreeunlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Actgrand larceny, orpetit larceny or shopliftingInformation regarding ADA requirementsThe employer will note there is no information requested on the ODH Form 805, Uniform Employment Application for Nurse Aide Staff, pertaining to the Americans with Disabilities Act (ADA). However, it should be noted that any qualified applicant with a disability may request reasonable accommodation(s) to complete the application/interview process. The specific nature of the accommodation and the reason for the request must be indicated at the time the application is requested. All other ADA requirements related to the hiring process must be met according to the employer's procedure and be in compliance with the ADA.Pursuant to 63 O.S. 1-1950. 1(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended, suspended, or subject to parole.Uniform Employment Application for Nurse Aide Staff Effective November 1, 2012This application form is required by Title 63 O.S. § 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuing of care facilities, hospice programs, adult day care centers, and home care agencies.This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color. sex. religion, citizenship, national origin, veteran status, age, or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.ATTENTION NURSE AIDES: RETURN YOUR COMPLETED APPLICATION TO EMPLOYER.Date of Application *Date Available to Start Work *Personal InformationFirst Name *Middle NameLast Name *Email Address *Phone Number *Social Security Number *Sex *Race *Date of Birth *Have you previously worked under a different name? *YesNoList any other name(s) you have previously worked underPresent AddressAddress Line 1 *Address Line 2City *State *ZIP Code *Is your permanent address different than your present address? *YesNoPermanent AddressAddress Line 1 *Address Line 2City *State *ZIP Code *Emergency Contact PersonFirst NameLast NameStreet AddressPhone NumberEmployment DesiredPosition Applied ForSalary RequiredHours available to work *DaysEveningsNightsWeekendsWill you accept employment of *Full TimePart TimeOccasional Part TimeHave you ever served in the U.S. Military? *YesNoBranchDate EnteredDate DischargedType of DischargePrior Work HistoryList up to your last 4 jobs beginning with your most recent or current employer.Employer First NameEmployer Last NameEmployer Telephone NumberEmployer AddressCityStateZIP CodePosition HeldSupervisorSalaryEmployment Start DateEmployment End DateReason for LeavingHave you ever been terminated or asked to resign from any position? *YesNoWhy so?Send Message
