By execution of this document, I acknowledge that I have been informed by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on an emergency basis and that my employment is
temporary pending the results of the criminal history check. I also understand that if I have been convicted of the following offenses, that I may not be employed by this Agency. I also understand that the Agency will search the Employee Misconduct Registry and the Nurse Aide Registry (if applicable) to determine whether any acts of abuse,
neglect or exploitation have occurred and whether my name is designated on either Registry. If my name is
designated on either registry I understand the Agency must deny me employment.
Offenses which constitute a bar to employment and for which an administrative review is not available, are offenses under:
Chapter 19, Penal Code (Criminal homicide)
Chapter 20, Penal Code (Kidnapping and unlawful restraint)
Chapter 21.11, Penal Code (Indecency with a child)
Chapter 22.02, Penal Code (aggravated assault)
Chapter 22.04, Penal Code (injury to a child, elderly individual, or disabled individual)
Chapter 22.041, Penal Code (abandoning or endangering a child)
Chapter 25.031 Penal Code (Agreement to abduct from custody)
Chapter 25.06, Penal Code (Solicitation of a child)
Chapter 25.11, Penal Code (Sale or purchase of a child)
Chapter 28.08, Penal Code (Arson)
Chapter 29.02, Penal Code (Robbery)
Chapter 29.30, Penal Code (Aggravated robbery)or
A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice of an offense containing elements that are substantially similar to the elements of an offense listed under the above Subdivision.
A person convicted of an offense under Chapter 31, Penal Code (theft), that is punishable by a felony may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date of the conviction. (This requirement only applies to those employees first employed by the facility or Agency on or after September 1, 2003).
A person convicted of an offense under section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
An offense under sec6tion 30.02, Penal Code (burglary)
An offense under section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or as a felony; or
An offense under section 32.45 Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor of a felony.
I understand that all information obtained by this Agency regarding any criminal history will remain confidential. By signing this form, I certify that the information on this form contains no willful misrepresentation and that the information is true and complete to the best of my knowledge.