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JOB APPLICATION

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Employer Instructions for Use — ODH Form 805 Uniform Employment Application for Nurse Aide Staff

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.

ATTENTION NURSE AIDES: RETURN YOUR COMPLETED APPLICATION TO EMPLOYER.

Date of Application*

Date Available to Start Work*

1. Personal Information

Name*

First Middle Last

Email*

Social Security Number*

List any other name(s) you have previously worked under*

Present Address*

Street Address Address Line 2 City State ZIP Code

Permanent Address (if different than present address):*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Sex*

Date of Birth*

Race*

For purposes of Criminal History Records Search

Emergency Contact Person*

First Last

Address*

Street Address

Phone*

2. Employment Desired

Position applied for*

Salary required*

Hours available to work*

Days*

Evenings*

Nights*

Weekends*

Will you accept employment of*

Full Time?*

Part Time?*

Occasional Part Time?*

3. U.S. Military Record

Branch

Date Entered

Date Discharged

Type of Discharge

4. Prior Work History

List your last four (4) jobs beginning with your most recent or current employer.

Employers Name*

First Last

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed From*

Month/Year

Date Employed To*

Month/Year

Salary*

Reason for Leaving*

Employer 2

Employers Name*

First Last

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed From*

Month/Year

Date Employed To*

Month/Year

Salary*

Reason for Leaving*

Employer 3

Employers Name*

First Last

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed From*

Month/Year

Date Employed To*

Month/Year

Salary*

Reason for Leaving*

Employer 4

Employers Name*

First Last

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed From*

Month/Year

Date Employed To*

Salary*

Reason for Leaving*

List name(s) of all other employers for the last five (5) years:*

Yes

Not applicable

Have you ever been terminated or asked to resign from any position?*

If yes, provide reason.*

7. References

List name, address and telephone number of three (3) references who are not relatives or former employers.

Name*

First Last

Phone*

Address*

Street Address City State ZIP Code

Name*

First Last

Phone*

Address*

Street Address City State ZIP Code

Name*

First Last

Phone*

Address*

Street Address City State ZIP Code

8. Background Information

If you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to:

State and/or jurisdiction.

Nature of complaint/offense.

Disposition of complaint and/or offense (e.g., "dismissed insufficient evidence", "deferred sentence").

Date of disposition.

Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

A. Have you ever: I ) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pled guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?*

If yes, explain here*

B. Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession?*

If yes, explain here*

C. Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA*

If yes, explain here*

D. Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?*

If yes, explain here*

9. Applicant's Certification and Agreement

Please Read Carefully - If you answer 'No' to any of the questions below, explain in the space after the question.

A. I understand the employer has the right to proceed with any criminal background check.*

If No, explain here*

B. I understand as a part of the job selection process, I may be required to take a drug-screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. If 1 refuse to sign this form and submit to drug testing, the employer will reject my application.*

If No, explain here*

C. I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer.*

If No, explain here*

D. I understand if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986.*

If No, explain here*

E. I understand this form is not an employment contract.*

If No, explain here*

10. Previous CNA Training

Complete this section only if you will require training.

Please complete the following if you have had CNA Training in the past for any of these categories: LTC, HH, ADC, RC, or DDDC.

Category*

Program Name*

Start Date*

Month/Year

End Date*

Month/Year

Category*

Program Name*

Start Date*

Month/Year

End Date*

Month/Year

Category*

Program Name*

Start Date*

Month/Year

End Date*

Month/Year

Category*

Program Name*

Start Date*

Month/Year

End Date*

Month/Year

11. Important Information for the Job Applicant

It is unlawful for any person to provide false information regarding a criminal conviction on this uniform employment application for nurse aides. Providing false information regarding a criminal conviction is a misdemeanor under Title 63 of the Oklahoma Statutes, Section 1-1950.4a. Providing false information about a criminal conviction on this application is punishable by a fine not to exceed Five Hundred Dollars ($500.00), by imprisonment in the county jail for a term of not more than one (1) year, or by both such fine and imprisonment.

* * * NOTICE * * *

I UNDERSTAND PROVIDING FALSE OR MISLEADING INFORMATION TO A TRAINING PROGRAM, A FACILITY, OR THE DEPARTMENT IS GROUNDS FOR DENIAL, SUSPENSION, WITHDRAWAL, AND/OR NONRENEWAL OF CERTIFICATION. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION OR OMISSION OF FACTS MAY DISQUALIFY ME FROM EMPLOYMENT AND MAY CAUSE TERMINATION IF DISCOVERED AT A LATER DATE.*

Insert your initials above.

I certify I have read and completed this application and that the information I have provided on this application is true and complete.*

Sign by writing your Full Name

Date of Signature*

12. Criminal Arrest Check List

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered if the below signed individual has been convicted or 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, as stated by Oklahoma Statute, Section 1-1950.1(C)(1) of Title 63:

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.

Effective November I, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered for the below signed individual if less than seven (7) years have elapsed since the completion of sentence, and the results of a criminal history check revealed 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, as stated by Oklahoma Statute, Section 1-1950.1(C)(2) of Title 63:

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.

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, or subject to parole.

It is further understood that if I am hired, it will be as a temporary employee until the employer receives my criminal background check. If I have no criminal record in accordance with state law, I may be considered for employment, subject to training requirements and other requirements of the job for which I am applying with this employer.

13. Consent and Release Form

I understand the OSDH will store the records of an employer's enrolled employees, the results of the screening and criminal arrest records search, and an identifier issued by the OSBI for the purposes of receiving an automatic notification from the OSBI if a subsequent criminal arrest record submitted into the system matches a set of fingerprints previously submitted. When there is a match, the OSBI will notify the Department and the Department will notify the employee. This information is confidential, is not subject to disclosure under the Oklahoma Open Records Act, and shall not be disclosed to any person except for purposes of this act or for law enforcement purposes. I will promptly respond to Department inquiries regarding the status of an arraignment or indictment.

Your employer must submit your name, any aliases, address, former states in which you resided, social security number, and date of birth. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application. PLEASE PRINT CLEARLY. The names used must appear as recorded on your birth certificate or other official record.

First Name*

Middle Name*

Maiden Name (if applicable)*

Last Name*

What other aliases/names have you used?*

Date of Birth*

State and County of Birth*

US Citizen*

Race*

Gender*

Height*

Weight*

Hair Color*

Eye Color*

Phone Number*

Phone Number Type*

Home

Mobile

Social Security Number*

Current Address*

Current City / State / ZIP*

In what other states have you lived after 17 years of age?*

Email Address*

My signature acknowledges that I have read, understand and accept the terms and conditions outlined in this form. I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the FBI. Both agencies will conduct a state and national criminal history records check and retain my fingerprints for comparison against other fingerprints submitted to, or retained by, the OSBI or FBI. I received an Attachment to this form: "How to Request My Criminal History Report and Complete, or Challenge the Information."

Signature of Applicant*

Sign by writing your full name

Date of Signature*

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111 e Chickasaw, Sallisaw
Oklahoma 74955
(918) 774-9696

Triacle

JOB APPLICATION

Pre-Employment Questionnaire

Employer Instructions for Use — ODH Form 805 Uniform Employment Application for Nurse Aide Staff

1. Personal Information

2. Employment Desired

3. U.S. Military Record

4. Prior Work History

Employer 2

Employer 3

Employer 4

5. Educational Background

6. Certification

7. References

8. Background Information

9. Applicant's Certification and Agreement

11. Important Information for the Job Applicant

12. Criminal Arrest Check List

13. Consent and Release Form

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