An ineligible person is any individual or entity who is currently excluded, suspended, debarred or otherwise ineligible to participate in Federal Health Care programs; or has been convicted of a criminal offense related to the provision of
health care items or services and has not been reinstated in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility.

Please Review and Sign Where Indicated.

In making application for employment:

• I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
• I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, persona characteristics, and mode of living, whichever may be applicable. If such an
  investigative report is made, I understand that I will receive  notice that such report has been requested, and that I will
  have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
• I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.
• I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.
• Compliance with this facility’s Substance Abuse Policy is a condition of employment. This hospital requires that newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital’s Alcohol and Drug Abuse Policy.
• I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

RELEASE:

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

STATEMENT OF EMPLOYABLILITY

By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General's List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act. Criminal

History Check
I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact or have access to patient records until results are returned. I will be notified of results.

CONVICTIONS BARRING EMPLOYMENT.
(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

• An offense under Chapter 19, Penal Code (criminal homicide);
• An offense under Chapter 20, Penal Code (kidnaping and unlawful restraint);
• An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
• An offense under Section 21.08, Penal Code (indecent exposure);
• An offense under Section 21.11, Penal Code (indecency with a child);
• An offense under Section 21.12, Penal Code (improper relationship between educator and student);
• An offense under Section 21.15, Penal Code (improper photography or visual recording);
• An offense under Section 22.011, Penal Code (sexual assault);
• An offense under Section 22.02, Penal Code (aggravated assault);
• An offense under Section 22.021, Penal Code (aggravated sexual assault);
• An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);
• An offense under Section 22.041, Penal Code (abandoning or endangering a child);
• An offense under Section 22.05, Penal Code (deadly conduct);
• An offense under Section 22,07, Penal Code (terroristic threat);
• An offense under Section 22.08, Penal Code (aiding suicide);
• An offense under Section 25.031, Penal Code (agreement to abduct from custody);
• An offense under Section 25.08, Penal Code (sale or purchase of a child);
• An offense under Section 28.02, Penal Code (arson);
• An offense under Section 29.02, Penal Code (robbery);
• An offense under Section 29.03, Penal Code (aggravated robbery);
• An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);
• An offense under Section 33.021, Penal Code (online solicitation of a minor);
• An offense under Section 34.02, Penal Code (money laundering);
• An offense under Section 35A.02, Penal Code (Medicaid fraud); An offense under Section 36.06, Penal Code (obstruction or retaliation);
• An offense under Section 42.09, Penal Code (cruelty to livestock animals);
• An offense under Section 42.092, Penal Code (cruelty to nonlivestock animals); or
• A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
• An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves

(B) A person may also be barred from employment the duties of which involve direct contact with a client in a facility if convicted of any of the following crimes within the past 5 years:

• An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony);
• An offense under Section 30.02 , Penal Code (burglary);
• An offense under Chapter 31, Penal Code (theft that is punishable as a felony);
• 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 a felony; or
• An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony).
• An offense under Section 37.12, Penal Code (false identification as a peace officer); or
• An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).

(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:

• Of an offense under Section 30.02, Penal Code (burglary); or
• Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.

(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

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For Agency Use Only: Criminal History, Employee Misconduct Registry (EMR), Nurse Aide Registry (NAR), and LEIE checks completed:

❑Criminal History Check completed on-line ❑ Other Convictions identified on Criminal History. (Document reason hiring in Comments below)
❑NAR       ❑ EMR checked online at https://emr.dads.state.tx.us/DadsEMRWeb/      ❑ LEIE
❑Applicant employable ____ ❑ Applicant not employable ❑ Comments: _______________________________

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Verified By ___________________________________________  Date __________________________________

ELCL / Background Check
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