Purpose
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 Information
Employment Desired
U.S. Military Record
Prior Work History
Educational Background
Certification
References
Background Information
Applicant's Certification and Agreement
Previous 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 person
rape, incest, or sodomy
child abuse
murder or attempted murder
manslaughter
kidnapping
aggravated assault and battery
assault and battery with a dangerous weapon, or
arson 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:
assault
battery
indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender
pandering
burglary in the first or second degree
robbery in the first or second degree
robbery or attempted robbery with a dangerous weapon, or imitation firearm
arson in the second degree
unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act
grand larceny, or
petit larceny or shoplifting
Information regarding ADA requirements
The 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, 2012
This 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.