[---------------- For purposes of Criminal history records search ------------------]
Emergency Contact Person:
Hours available to work:
Employment Information #1
Employment Information #2
Employment Information #3
Employment Information #4
List all educational schools attended with degrees, diplomas, or certificates received.
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 is not limited to:
PLEASE READ CAREFULLY - If you answer ‘no’ to any of the questions below, explain in the space after the question.
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.
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.
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.
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(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 the authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1-1950.1(B).
I authorize Oxford HealthCare and/or its agents, including consumer-reporting bureaus, to verify my employment experience. I also authorize any reference source to provide Oxford HealthCare with any and all information covering my background and hereby release any said sources from any liability for any damage whatsoever for issuing this information. A copy of this document shall have the same force and effect as the original.
RELEASE OF INFORMATION
I agree that if the company or its employees are subject to review or investigation for accreditation or law enforcement purposes or to remain a participant in federal health care programs, I will cooperate in such investigations, which may include the release of information related to my employment with the company.
AT WILL EMPLOYMENT
I understand and agree that any employment offered to me will not be for any definite period of time and is subject to termination with or without cause by the company or myself at any time. I further understand and agree that my employment will be “at will,” that no statements have been made to the contrary and that this policy cannot be changed except in writing, signed by an authorized officer of the company.
I give full permission and authorization to have Oxford HealthCare and/or its agent send a specimen of my urine and/or blood to a laboratory for screening using N.I.D.A. standards for the presence of illegal drugs, alcohol, or prescription medication taken without a prescription.
I will hold all parties involved harmless, meaning I will not send or hold them responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment as a result of not submitting to the tests or as a result of the determination of the testing. This includes, but is not limited to any possible clerical or laboratory errors made.
I understand that this is a legally binding document, which is binding because Oxford HealthCare is both sending me for the examination and paying for the examination. I fully understand the wording of this document.
Should an accident occur while on assignment, I understand that a drug or alcohol screen will be required immediately. Additionally, I understand that when my employer has a valid suspicion of my drug use and a further belief that my poor performance is directly related to such drug use, then I may be subject to a drug test.
My refusal to submit to the drug or alcohol testing under the terms and conditions outlined herein above will be grounds for immediate termination.
Any positive drug test result may result in my immediate termination.
hereby understand that as a condition of my employment, I may be subject to drug/alcohol testing for the following reasons:
My signature below indicates my acknowledgement that, should a drug/alcohol test be requested or be appropriate under the above drug/alcohol screen authorization and consent, and if I fail a test or refuse to submit the required blood or urine sample for the authorized screen, such failure or refusal, for whatever reason, will be grounds for termination.
(Specify hours each week)
TASKS & ACTIVITIES:
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. Upon notification, the OSBI will immediately notify the Department and the Department will immediately notify the employee.
Information in the database established under this subsection 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. The employee shall promptly respond to Department inquiries regarding the status of an arraignment or indictment. Reporting of an arraignment or indictment under this subsection may be cause for leave without pay, placement under direct supervision, restriction from direct patient access, termination, or denial of employment. [63 O.S. § 1-1947(S)].
Pursuant to 63 O.S. § 1-1947(l)(1), the employer shall submit the applicant’s name, any aliases, address, former states in which the applicant 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.
This form requests this information for the purposes of a state and national criminal history records search. These names must appear as recorded on your birth certificate or other official record.
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 for conducting a state and national criminal history records check.