Activities Assistant

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, continuum 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.

For purposes of Criminal History Records Search

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

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:

1. State and/or jurisdiction.
2. Nature of complaint/offense
3. Disposition of complaint and/or offense (e.g., "dismissed insufficient evidence", "deferred sentence").
4. Date of disposition
5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

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

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

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 l-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.

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

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 of, pied 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.l(C)(l) of Title 63:

1. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
2. rape, incest or sodomy,
3. child abuse,
4. murder or attempted murder,
5. manslaughter,
6. kidnapping,
7. aggravated assault and battery,
8. assault and battery with a dangerous weapon, or
9. arson in the first degree.

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 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 reveal that the subject person has been convicted of, or pied 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.l(C)(2) of Title 63:

1. assault,
2. battery
3. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
4. pandering,
5. burglary in the first or second degree,
6. robbery in the first or second degree,
7. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
8. arson in the second degree,
9. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
10. grand larceny, or
11. petit larceny or shoplifting.

Pursuant to 63 O.S. § 1-1950.l(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.

I hereby certify I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section 1-1950.l(C). My signature below authorizes the employer to run a check with the Nurse Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of resident's property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.l(B).