Employer Instructions for Use - ODH Form 805 Uniform Employment Application for Nurse Aide Staff

Purpose

This form is to be used by employers as the only employment application for hiring nurse aide staff 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 as mandated by Title 63 O.S. § 1-1950.4, Uniform Employment Application for Nurse Aide Staff - Purpose - Training. The content of this form shall not be altered.

Employer Instructions

Provide this form to all applicants seeking employment as a nurse aide. The form may be duplicated as needed.

• Instruct the applicant to complete each section of this form.

1. Personal Information
2. Employment Desired
3. U.S. Military Record
4. Prior Work History
5. Educational Background
6. Certification
7. References
8. Background Information
9. Applicant‟s Certification and Agreement
10. Previous CNA Training: If the applicant will require nurse aide training, instruct to complete section 10
    on page 4.

NOTE: If the facility has an approved nurse aide temporary emergency waiver, the applicant must be trained and certified within four (4) months of hire date.

Category: List any CNA training received in the past by type of training: Long Term Care Aide (LTCA), Home Health Aide (HHA), Adult Day Care Aide (ADCA), Residential Care Aide (RCA) and Developmentally Disabled Direct Care Aide (DDDCA

Program Name: List the title of the training program where the training was received.

Training Days: List the number of days of training completed for each category.

11. Important Information for the Job Applicant

Instruct applicant to read and initial in the gray 'NOTICE' box on page 5, then sign and date certifying the application is true and complete.

12. Criminal Arrest Check

Instruct the applicant to read and complete the „Criminal Arrest Check List‟ section on page 5. Obtain the applicant‟s signature and date in the designated spaces.
Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1(C) states:

§63-1-1950.1. Definitions - Criminal arrest check on certain persons offered employment - Exemptions.
………………………………………………………………………………………………..
C. 1. If the results of a criminal history background check reveal that the subject person 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, the employer shall not hire or contract with the person:

1. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
2. rape, incest or sodomy,
3. child abuse,
4. murder or attempted murder,
5. manslaughter,
6. kidnapping,
7. aggravated assault and battery,
8. assault and battery with a dangerous weapon, or
9. arson in the first degree.

2. If less than seven (7) years have elapsed since the completion of sentence¹, 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, the employer shall not hire or contract with the person:

1. assault,
2. battery,
3. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
4. pandering,
5. burglary in the first or second degree,
6. robbery in the first or second degree,
7. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
8. arson in the second degree,
9. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
10. grand larceny, or
11. petit larceny or shoplifting.

• Information regarding ADA requirements
  The employer will note there is no information requested on the ODH Form 805, Uniform Employment Application for Nurse Aide Staff, pertaining to the Americans with Disabilities Act (ADA). However, it
  should be noted that any qualified applicant with a disability may request reasonable accommodation(s) to complete the application/interview process. The specific nature of the accommodation and the reason for the
  request must be indicated at the time the application is requested. All other ADA requirements related to the hiring process must be met according to the employer‟s procedure and be in compliance with the ADA.

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.

__________________

1 Pursuant to 63 O.S. § 1-1950.1(A)(5), "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.

 

 

Uniform Employment Application for Nurse Aide Staff

1. Personal Information

Present Address:

Permanent Address (if different than present address):

Emergency Contact Person:

2. Employment Desired

3. U.S. Military Record

4. Prior Work History List your last four (4) jobs beginning with your most recent or current employer.

Dates Employed:

Dates Employed:

Dates Employed:

Dates Employed:

5. Educational Background List all educational schools attended with degrees, diplomas or certificates received.

6. Certification

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.

 

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.

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.

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.

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(C)(1) of Title 63:

1. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
2. rape, incest or sodomy,
3. child abuse,
4. murder or attempted murder,
5. manslaughter,
6. kidnapping,
7. aggravated assault and battery,
8. assault and battery with a dangerous weapon, or
9. 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 elapsed since the completion of sentence¹, 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(C)(2) of Title 63:

1. assault
2. battery,
3. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
4. pandering,
5. burglary in the first or second degree,
6. robbery in the first or second degree,
7. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
8. arson in the second degree,
9. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
10. grand larceny, or
11. 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(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 authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1-1950.1(B).

Crimes That May Block Your Employment

Long Term Care Security Act – Title 63 O.S. Section 1-1945 et. seq.

You must be fingerprinted to work with this employer. We will do a national background check and an arrest in any state is reviewed. Your fingerprints will be used to check the criminal history records of the FBI. The FBI will retain your fingerprints and associated information/biometrics and, while retained, your fingerprints will continue to be compared against other fingerprints submitted to, or retained by, the FBI.

If convicted for a crime listed below, you may not be able to work for nursing, assisted living, adult day care, and residential care facilities; homes for the developmentally disabled; group homes; home health and hospice agencies. These crimes apply to nurse aides, activity, social services, kitchen, housekeeping, maintenance and other non-licensed jobs. Licensure Boards define the crimes that apply for licensed health care professionals. Tell this provider if you were fingerprinted for your license. Your arrest history will be monitored. If sentenced for any disqualifying crimes while employed you may lose your job.

You will be found not eligible for a job with these employers if you were ever sentenced for one of the following crimes or a related crime1:

You will be found not eligible for a job with these employers if you were ever sentenced for one of the following crimes or a related crime and less than seven (7) years has passed since you completed the terms of your sentence, including any period of deferment2:

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

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 If the results of a criminal history background check reveal that the subject person 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, the employer shall not hire or contract with the person. [63 O.S. § 1-1950.1(C)(1)]

² If less than seven (7) years have 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, the employer shall not hire or contract with the person [63 O.S. § 1-1950.1(C)(2)]

* The law defines "Completion of the sentence" to mean 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 [63 O.S. § 1-1950.1(A)(5)]
 

This form is a provided as a courtesy for the use of employers. Other versions are allowed to meet Title 63 O.S. § 1-1947(H), which requires that an applicant shall provide the employer a government photo identification of the applicant and written consent for the employer to conduct a registry screening and the [Okla. State Bureau of Investigation (OSBI)] to conduct a state and national criminal history record check under this section. The employer shall maintain the written consent and information regarding the individual’s identification in their files for audit purposes. It is recommended a copy of the identification be maintained with the applicant's written consent.

EMPLOYER MUST RETAIN THIS SIGNED APPLICANT CONSENT.

Instructions to Applicant: [63 O.S. 1-1945 et. seq.] Evidence of an applicant's consent to a check of state and/or national licensure, certification, abuse, exclusion and offender registries, and fingerprinting for a state and national criminal history records check is required. If you have an active employment history in OK-SCREEN, new fingerprints may not be needed. New registry checks must be done. With your consent, the employer will submit your information through the OK-SCREEN web portal for checks against state and national registries. If you are cleared, and the employer wishes to continue, you will get an email or telephone notice to schedule an appointment for fingerprinting, if required. You will be responsible for a Ten Dollar ($10) processing fee at the time the appointment is scheduled unless the employer elects to pay the fee. You will have ten (10) calendar days to submit your fingerprints or you will be required to start over [63 O.S. § 1-1947(I)(4)].

Declarations: By signing this form I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the Federal Bureau of Investigation for the purpose of conducting a state and national criminal history records check pursuant to 63 O.S. § 1-1947(H). I understand that the results will be shared with the Oklahoma National Background Check Program (ONBCP) operated by the Oklahoma State Department of Health (OSDH). I understand that if my criminal history results reveal information that prevents the Department from making a final determination, I will be given notice and will have sixty (60) days to make corrections or additions. If I am unable to make corrections or additions within the sixty (60) days, the Department will either deny me eligibility based on the disqualifying results or advise me they cannot make a determination and notify me of my right to appeal. The notice shall include the reasons I was found not eligible for employment and a statement that I have a right to appeal. [63 O.S. § 1-1947(K)]

I understand that as a condition of employment, I agree to report to the employer immediately upon being arraigned, indicted, convicted, or pleading guilty or nolo contendere to one or more of the criminal offenses applicable to my license, certification, permit or employment class; or upon being the subject of a substantiated finding on a registry as described in this Consent and Release and Title 63, Section 1-1947. I understand an arraignment may also be cause for employment restrictions or termination. [63 O.S. § 1-1947(Q)]

FBI Privacy Act Statement Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

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. When there is a match, the OSBI will notify the Department and the Department will notify the employee. This information 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. I will promptly respond to Department inquiries regarding the status of an arraignment or indictment.

Your employer must submit your name, any aliases, address, former states in which you 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. PLEASE PRINT CLEARLY. The names used must appear as recorded on your birth certificate or other official record.

The following information from the previous pages have been autofilled into the background check consent form to save you time. Please review and correct on previous pages if needed:

Full Name:{name226}

Maiden Name or Other Aliases/Names: {listAny}

Race: {race}

Phone Number: {phoneNumber}

Social Security Number: {socialSecurity}

Current Address: {street} {city}, {state} {zip16}

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. Both agencies will conduct a state and national criminal history records check and retain my fingerprints for comparison against other fingerprints submitted to, or retained by, the OSBI or FBI. I received an Attachment to this form: "How to Request My Criminal History Report and Complete, or Challenge the Information."

How to Request My Criminal History Report and Complete, or Challenge the Information

To request your report, after you have fingerprinted email okscreen@health.ok.gov
or call 1-855-584-3550

Updating Criminal Records – OKLAHOMA

Updating your criminal records must be accomplished through the Oklahoma State Bureau of
Investigation (OSBI) or in combination with the State in which the arrest or conviction occurred and
the Federal Bureau of Investigation. The Oklahoma National Background Check Program (ONBCP) at
the Oklahoma State Department of Health cannot change your criminal records.

CHANGE IN LAW REMOVES FEES FOR UPDATING RECORD: Effective November 1, 2015, all filing fees and court costs paid by a petitioner to file an expungement request will be returned if the person qualifies for an expungement. The OSBI fee will be waived if the subject of the criminal history record has been granted an expungement under the provisions listed in Title 22 of the Oklahoma Statues

The following Certified documents are required to update a criminal record with a final disposition.
Without these documents the OSBI cannot update your record.

• If charges were filed (you went to court or were represented in court by an attorney)

A Certified copy of the final disposition should be obtained from the Court Clerk’s Office in the county of arrest. If charges were handled in city court, contact the municipal court in the city of arrest.

• If you received a deferred sentence and upon successful completion –

A Certified copy of the deferred dismissal should be obtained from the Court Clerk’s Office in the county* of arrest. If the case is no longer on file at the Court Clerk’s Office, contact the District
Attorney’s Office for a certified copy. Oklahoma County & Tulsa County District Attorney’s Offices will assist only subject(s) who have received a deferred sentence.

*If charges were handled in city court, contact the municipal court in the city of arrest.

Note: State law does not allow for the complete removal of an arrest that results in a deferred sentence. The arrest will always be a part of the criminal record and the disposition will be updated to read Pled Not Guilty, Case Dismissed, resulting in no conviction for that arrest.

• If charges were not filed (you did not go to court nor did an attorney appear in court on your behalf) you must obtain 3 certified documents, exception Oklahoma County and Tulsa County you will only have 2 certified documents. The necessary documents are explained below:

A Certified letter must be obtained stating there is no record of the arrest in the files of the
County and/or City Court Clerk. The letter must be signed and certified by the County and/or City Court Clerk, and

A Certified letter must be obtained from the District Attorney’s Office in the county of the arrest. This letter must be written on District Attorney office letterhead and signed by the District Attorney or Assistant District Attorney stating there is no record of the arrest in the files of the District Attorney.

In addition, when no record exists at the Court Clerk’s Office or the District Attorney’s Office, a certified copy of the arrest/incident report relating to that arrest must be obtained from the arresting agency.

You may call the automated-attendant line (405) 879-2690 for additional information.

Web: https://osbi.ok.gov/criminal-history/update-criminal-history

Email: RAP-Sheet-Question@osbi.ok.gov
 

Challenge of a Criminal History Summary – FBI’s Criminal Justice Information Services (CJIS) Division

The FBI’s Criminal Justice Information Services (CJIS) Division serves as the nation’s central repository and custodian for fingerprints and related Criminal History Summary information. As custodian of such information, the CJIS Division does not have the authority to modify any Criminal History Summary information unless specifically notified to do so by the agency that owns the information. If you believe your Criminal History Summary contains inaccurate or incomplete information, you have two options for requesting a change or correction:

Option 1: Contact the agency or agencies that submitted the information to the FBI.

Missing or Incorrect State (Non-Federal) Information

Most states, through agreement with the FBI, require that modification requests for Criminal History Summary information be processed through their respective state central repository (State Identification Bureau) before any update can be applied by the FBI to its record. You may contact the respective state repository(ies) for assistance, and, if applicable, request that they provide the FBI with updates to your Criminal History Summary. Contact information for each state is provided here:
https://www.fbi.gov/services/cjis/identity-history-summary-checks/state-identification-bureau-listing

Several states maintain their own record system. Record updates are made at the state level only, so the FBI cannot modify its records. Instead, the FBI accesses the state’s system for authorized purposes to review the record. Contact information for states maintaining records at the state level is provided here:

https://www.fbi.gov/services/cjis/identity-history-summary-checks/state-maintained-records-listing.

Missing or Incorrect Federal Information

For federal Criminal History Summary updates,
the FBI must receive a request directly from the
original arresting agency, from a court with
jurisdiction over the arrest data, or from another
agency with jurisdiction over the arrest data.

Option 2: Electronically submit your challenge request directly to the FBI

Step 1: Go to https://www.edo.cjis.gov

Step 2: Follow the steps under the “Challenging Your Identity History Summary” section.

If you submitted a challenge request electronically directly to the FBI, you will receive a response electronically and an option to receive a response by First-Class Mail via the U.S. Postal Service.

Option 3: Send a written challenge request to the FBI’s CJIS Division.

Your written request should clearly identify the information that you feel is inaccurate or incomplete and should include copies of any available proof or supporting documentation to support your claim. For example, if your disposition information is incorrect or missing, you may submit documentation obtained from the court having control over the arrest or the office prosecuting the offense. The FBI will contact appropriate agencies in an attempt to verify or correct challenged entries for you. Upon receipt of an official communication from the agency with control over the data, the FBI will make appropriate changes and notify you of the outcome.

You may submit an Identity History Summary challenge to the FBI by writing to the following address:

FBI CJIS Division
Attention: Criminal History Analysis Team 1
1000 Custer Hollow Road
Clarksburg, WV 2630

Web: http://www.fbi.gov/about-us/cjis/criminal-history-summary-checks/challenge-of-a-criminal-history-summary

Oklahoma National Background Check Program - http://ONBC.health.ok.gov