Spring/Summer 2015 | Baptist Village Communities

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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*

How did you learn about this position?*

Location of Work Requested*

1. Personal Information

Last 4 of Social Security Number:*

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

Date of Birth:*

For purposes of Criminal History Records Search

Emergency Contact Person

2. Employment Desired

Position Applied For*

3. U.S. Military Record

Date Entered

Date Discharged

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

Dates Employed: From (month/year)*

Dates Employed: From (month/year)

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

If yes, provide reason.

5. Educational Background

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

List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed*

If yes, where and when did you obtain

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.

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.

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.

Start Date

End Date

Start Date

End Date

Start Date

End Date

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.

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

Comments

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Application Date*

Date Available to Start Work*

Personal Information

Location Applying For*

Position(s) Applied For*

Rate of Pay Desired*

Shift*

Please indicate hours of availability.

How did you learn about this position?*

If referred by a current employee, please tell us their name so we can thank them.*

Please write N/A if not referred by current employee.

When did you last apply?

Name of Related Person

If yes, please specify

References

(do not include relatives or former employers)

Name and Occupation*

Education and Training

Name of High School*

Other Education/Training

Grade/Year Completed

Employment and Record

(list last or present position first) If any breaks or gaps in employment exist, please briefly explain below.

Date Employed From*

Date Employed To*

Starting Salary Range*

Ending Salary Range*

Position and Duties*

Date Employed From

Date Employed To

Starting Salary Range

Date Employed From

Date Employed To

Starting Salary Range

Date Employed From

Date Employed To

Starting Salary Range

Date Employed From

Date Employed To

Starting Salary Range

If your former employment references, education or military service are under a name other than indicated on front of application, please indicate:*

(If not applicable, put N/A)

Professional Licenses and/or Certification

Organization or State

Date Issued

Organization or State

Date Issued

Organization or State

Date Issued

Please list all computer/software programs you are experienced in*

Example: Word, Excel, Outlook, PowerPoint, Publisher, Access, etc...

Office Equipment

(If not applicable, put N/A)

Why are you applying for a position in this ministry with senior adults?*

Employment Acknowledgment

(please read and sign)

Baptist Village Communities does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, 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.

As part of the application process, I voluntarily give Baptist Village Communities the right to make a thorough investigation of my past employment background and activities. I further agree to cooperate fully in such investigation. I hereby release from all liability and responsibility any and all persons, companies or entities which provide Baptist Village Communities with information or documents requested by Baptist Village Communities as part of the application process.

If I am hired by the company, I understand that my employment will be "at will," meaning either party - me or the company - will be able to terminate my employment at any time, with or without cause. I also understand that my employment may be terminated for any misstatement of fact appearing on, or omission of fact from, this application form.

Further, I understand that after I am given a conditional offer of employment, I may be required to undergo a physical examination as well as a background check screening as a prerequisite to my continued employment with the company. I hereby consent to take that physical examination and any such future physical examinations as are required by the company.

Finally, I understand that I, like every other employee of this company, will be required to complete an Employment Verification Form (I-9) within three (3) days of my employment. At that time, I will produce the documentation of my choosing which will satisfy the requirements stated on the I-9 form for proof of identity and eligibility for employment.

Employment Acknowledgement Date*

If your application is submitted successfully, you will receive a confirmation notification.

Please watch for notification of successful submission.

Comments

This field is for validation purposes and should be left unchanged.