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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, 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.

Date of Application*

Date Available to Start Work*

Were you referred by a current employee?*

If yes, please let us know who to thank.

First Name Last Name

Location of Work Requested*

1. Personal Information

Name*

First Middle Last

Last 4 of Social Security Number:*

List any other name(s) you have previously worked under, such as maiden name:*

Present Address*

Street Address City State ZIP Code

Permanent Address (if different than present address)

Street Address City State ZIP Code

Telephone #*

Date of Birth:*

Sex*

Male

Female

Race

For purposes of Criminal History Records Search

Emergency Contact Person

Name*

First Last

Address*

Phone Number*

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

Prior Work History

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

Employer's Name*

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed: From (month/year)*

To (month/year)*

Salary*

Reason for Leaving*

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

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

May we contact your present employer?*

Yes

No

Not Applicable

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

Yes

No

If yes, provide reason.

5. Educational Background

List all educational schools attended with degrees, diplomas or certificates received.*

Name of Institution (High School, Technical School, College)

Type of Studies

Dates Attended & Diplomas, etc.

If your school or employment records are under another name(s), indicate that name(s):

7. References

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

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: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pied 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?*

Yes

No

Explain

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

Yes

No

Explain

c. Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction?*

Yes

No

Explain

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?*

Yes

No

Explain

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.

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 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.

INITIAL HERE*

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

Hidden

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

Signature of Applicant

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 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:

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 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:

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.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).

Hidden

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).

Signature of Applicant

Date of Signature

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