SYNERGY Homecare | Uniform Employment Application for Nurse Aide Staff

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
MonthDayYear
Date
Date Available to Start Work
MonthDayYear
Date
Personal Information
Name
Last | First | Middle
Social Security Number
List any other name(s) you have previously worked under, such as maiden name
,
,
,
,
,
Present Address
Street | City | State | Zip
Permanent Address (if different than present address)
Street | City | State | Zip
Telephone #
Date of Birth
MonthDayYear
Date
Sex:
MaleFemale
Race:
Emergency Contact Person
Name | Address | Phone Number
2. Employment Desired
Position applied for
Salary required
Hours available to work:
DaysEveningsNightsWeekends
Will accept employment of:
Part-TimeFull TimeOccasional part time
3. U.S. Military Record
Branch
Date Entered
MonthDayYear
Date
Date Discharged
MonthDayYear
Date
Type of Discharge
4. 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
Position Held
Supervisor
Dates Employed: START (month/year)
MonthDayYear
Date
Dates Employed: END (month/year)
MonthDayYear
Date
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
Street | City | State | Zip
Position Held
Supervisor
Dates Employed: From (month/year)
MonthDayYear
Date
To (month/year)
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
Supervisor
Supervisor
Dates Employed: From (month/year)
MonthDayYear
Date
End Date: (MM/YYYY
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
Street | City | State | Zip
Position Held
Supervisor
Dates Employed: From (month/year)
MonthDayYear
Date
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?
YesNoNot applicable
Have you ever been terminated or asked to resign from any position?
YesNo
If yes, provide reason.
5. Educational Background List all educational schools attended with degrees, diplomas or certificates received.
5.
Name of Institution (High School, Technical School, College) Type of Studies Dates Attended & Diplomas, etc.
1
2
3
If your school or employment records are under another name(s), indicate that name(s)
6. Certification
If you hold a current certification as a nurse aide (CNA), check the appropriate certification(s) below:
Long Term Care (LTC)Adult Day Care (ADC)Residential Care Aide (RCA)Home Health Aide (HHA)Developmental Disability Aide (DDA)Certified Medication Aide (CMA)Certified Medication Aide-Gastrostomy (CMA-G)Certified Medication Aide-Glucose Monitoring (CMA-GM)Certified Medication Aide-Respiratory (CMA-R)Certified Medication Aide-Insulin Administration (CMA-IA)
List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed:
If you are a CMA, have you obtained your 8 hours of continuing education for the current 12-month certification period before your certification expires? Yes/No
YesNo
If yes, where and when did you obtain.
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:
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.
a. Yes/ No : Have you ever 1) 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?
YesNo
If yes, 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?
YesNo
If yes, 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?
YesNo
If yes, 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?
YesNo
If yes, explain:
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. Yes/No | I understand the employer has the right to proceed with any criminal background check.
YesNo
If yes, explain:
B. Yes/No | I understand as 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 I refuse to sign this form and submit to drug testing the employer will reject my application.
YesNo
If yes, explain:
C. Yes/No | I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examination as required by the employer
YesNo
If no, explain:
D. Yes/No | 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.
YesNo
If no, Explain:
E. Yes/No | I understand this form is not an employment contract.
YesNo
If 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.
Category
Program Name
Start Date
MonthDayYear
Date
End Date
MonthDayYear
Date
Category
Program Name
Start Date
MonthDayYear
Date
End Date
MonthDayYear
Date
Category
Program Name
Start Date
MonthDayYear
Date
End Date
MonthDayYear
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 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.
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
Clear
Signature Date
MonthDayYear
Date
Uniform Employment Application for Nurse Aide Staff
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, 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(C1) of Title 63:
a. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
b. rape, incest or sodomy,
c. child abuse,
d. murder or attempted murder,
e. manslaughter,
f. kidnapping,
g. aggravated assault and battery,
h. assault and battery with a dangerous weapon, or
i. 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 1 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, as stated by Oklahoma Statute, Section 1-1950.1(C2) of Title 63:
a. assault,
b. battery,
c. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
d. pandering,
e. burglary in the first or second degree,
f. robbery in the first or second degree,
g. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
h. arson in the second degree,
i. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
j. grand larceny, or
k. petit larceny or shoplifting.
1 Pursuant to 63 O.S. § 1-1950.1(A5), "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 1-1950.1(CMy 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 1-1950.01 (B).
fSignature of Applicant
Clear
Signature Date
MonthDayYear
Date
Oklahoma State Department of Health Protective Health Services
ODH Form 805 Revised 10/19/2012
Should be Empty:

	Name of Institution (High School, Technical School, College)	Type of Studies	Dates Attended & Diplomas, etc.
1
2
3

Uniform Employment Application for Nurse Aide Staff

Effective November 1, 2012

Personal Information

2. Employment Desired

3. U.S. Military Record

4. Prior Work history

9. Applicant’s Certification and Agreement