Sacred Heart Care Center, Inc. is an Equal Opportunity Employer

I certify the information given herein is true and complete to the best of my knowledge. I authorize this facility to contact any and/or all of my references for full information.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization if of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by authorized agent of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand also that I am required to abide by all rules and regulations of the employer.

MINNESOTA DEPARTMENT OF HEALTH LICENSED FACILITIES

SUPPLEMENTAL NURSING SERVICES AGENCIES, EDUCATIONAL PROGRAMS,

EMPLOYMENT AGENCIES, PROFESSIONAL SERVICES AGENCIES

BACKGROUND STUDY PRIVACY NOTICE

Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Date Practices Act requires that you be informed of the following:

1. Purpose and intended use of the information: Minnesota Statutes, section 144.057, requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. .The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS.

2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study.

3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified.

4. Known consequences that will arise from refusing to supply the requested information: only items identified as "optional" may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services.

5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private date and, except for the agencies noted, cannot be shared without your consent. 6a. If CURRENT background study results in a disqualification that is set aside upon reconsideration: If you are disqualified as a result your background study and you request reconsideration and your disqualification is set aside for the programs/agencies when the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C.15, subdivision 1 or 2; 2. The program that initiates the subsequent background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside; 3. The commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. The previous set aside was not limited to specific person(s) receiving services.

If the above criteria are not met, the notice of disqualification sent to the program/agency that initiates the subsequent background study will state that you are disqualification and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. (§245C.22, subd. 5)

6b. If a PREVIOUS background study resulted in disqualification that was set aside: If you were the subject of a previous background study which resulted in your disqualification, and your disqualification was set aside upon reconsideration, DHS will review the information in your record in connection with your current background study and determine whether the following criteria are met: 1. While you are disqualified, you are not disqualified for an offense specified in section 245C.15, subdivision 1 or 2; 2. The program that initiated the current background study is licensed or regulated under the same provisions of law and rule as the program for which your disqualification was previously set aside: 3. The commissioner has not received any new information to indicate that you may pose a risk of harm to any person served by the program; and 4. The previous set aside was not limited to specific person(s) receiving services.

If the above criteria are met, the notice of disqualification sent to the program/agency that initiated the current background study will state that you are disqualified and will include the reason you are disqualified. It will also state that your disqualification has been set aside for their program/agency, and that upon request, and without your consent, information about the factors that were the basis for the decision to set aside your disqualification are available to them. (§245C.22, subd. 5)

I have read and asked for clarification of above as needed.

To The Applicant: Please complete the upper portion of this form, including your signature and the date. It will be mailed by us to the employer listed and authorizes them to release information related to your employment.

Authorization is hereby granted to release Sacred Heart Care Center Inc., 1200 - 12th Street SW, Austin, MN 55912 any information regarding my employment at:

Applicants are considered for all positions, and employees are treated during employment without regard to race, color or creed, religion, sex, marital status, national origin, ancestry, age, handicap, status as a disabled or Vietnam era veteran, status with regard to public assistance, or affectional preference.

As an employer/government contractor, we comply with government regulations and affirmative action responsibilities.

To assist with government record keeping, reporting and other legal requirements, please fill out the Affirmative Action Survey.

Providing this information is voluntary and refusal to provide information will not have negative effect on your status as an applicant.

EQUAL EMPLOYMENT OPPORTUNITY POLICY STATEMENT

This is to affirm Sacred Heart Care Center's policy of providing Equal Opportunity to all employees and applicants for employment in accordance with all applicable Equal Employment Opportunity/Affirmative Action laws, directives and regulations of Federal, State and Local governing bodies or agencies thereof, specifically Minnesota Statures 363.

Sacred Heart Care Center will not discriminate against or harass any employee or applicant for employment because of race, color, creed, religion, national origin, sex, disability, age, marital status, status with regard to public assistance, or sexual orientation.

Sacred Heart Care Center will take Affirmative Action to ensure that all employment practices are free of such discrimination. Such employment practices include, but are not limited to, the following: hiring, upgrading, demotion, transfer, recruitment, or recruitment advertising, selection, layoff, disciplinary action, termination, rates of pay or other forms of compensation, and selection for training.

Sacred Heart Care Center will commit the necessary time and resources, both financial and human, to achieve the goals of Equal Employment Opportunity and Affirmative Action.

Sacred Heart Care Center will evaluate the performance of its management and supervisory personnel on the basis of their involvement in achieving these Affirmative Action objectives, as well as other established criteria. Any employee of this organization who does not comply with the Equal Employment Opportunity Policies and Procedures as set forth in this Statement and Plan will be subject to disciplinary action. Any subcontractor not complying with all applicable Equal Employment Opportunity/Affirmative Action laws, directives and regulations of the Federal State and Local governing bodies or agencies thereof, specifically Minnesota Statures 363, will be subject to appropriate legal sanctions.

Sacred Heart Care Center has appointed its Administrator Chris Schulz, to manage the Equal Employment Opportunity Program. Her responsibilities will include monitoring all Equal Employment Opportunity activities and reporting the effectiveness of this Affirmative Action Program, as required by Federal, Sate and Local agencies. She is also responsible for reviewing reports on the progress of the program with the Board of Directors.

If any employee or applicant for employment believes he/she has been discriminated against, please contact Chris Schulz, 1200 - 12th Street SW, Austin, MN 55912, or call (507) 433-1808.