OK Provisional Employment Form

Provisional Employment Form

This form is a provided as a courtesy for the use of employers. Other versions of this form may also be used for the purposes of Title 63 O.S. § 1-1947(L2), which requires a written statement from the applicant affirming and agreeing to the following:

1.The applicant is not disqualified from employment, an independent contract, or clinical privileges, based on the disqualifying criteria defined in subsection D of [Title 63 O.S. Section 1-1947];

2. The applicant agrees that, if the information in the registry screening and criminal history record check conducted under this section does not confirm the individual's statements under subparagraph a of this paragraph, his or her employment, independent contract, or clinical privileges shall be terminated by the employer as required under subsection D of [Title 63 O.S. Section 1-1947 unless and until the individual appeals and can provide that the information is incorrect;

3. That the applicant understands that the conditions described in paragraphs 1 and 2 may result in the termination of employment, independent contract, or clinical privileges, and that those conditions are good cause for termination; and

4. The period of provisional employment shall not exceed sixty (60) days pending the completion of the required background check. During this time the employee shall be subject to direct on-site supervision. The sixty-day time period may only be extended for those employees who are appealing the results of the background check. The time period shall only be extended for the duration of the appeal.

Where an individual is employed as a conditional employee, or has a conditional independent contract, or is granted conditional clinical privileges and the criminal history does not confirm the individual's statements under paragraph 1 above, the employer shall terminate the individual's employment, independent contract, or clinical privileges, as required by subsection E of [Title 63 O.S. Section 1-1947].

A signed copy of this form OR AN EQUIVALENT STATEMENT must be kept in the Human Resource file of the employee.

BEFORE BEGINNING PROVISIONAL EMPLOYMENT

THE EMPLOYER MUST COMPLETE THE REGISTRY SCREENINGS IN OK-SCREEN

THE EMPLOYER MUST REQUEST AUTHORIZATION TO FINGERPRINT

OR JOIN A PENDING DETERMINATION

THE APPLICANT MUST SIGN A STATEMENT AFFIRMING THE CONDITIONS FOR PROVISIONAL EMPLOYMENT

PLEASE INITIAL EACH ITEM.

I have not failed to comply with all federal, state and municipal laws as applicable to my professional license, certification, permit or employment class, as established by the authority having jurisdiction for my professional license, certification, permit, or employment class;I am not subject to an exclusion as described under Title 42 of the United States Code, Section 1320a-7;I am not currently the subject of a substantiated finding of neglect, abuse, verbal abuse, misappropriation of property, maltreatment, or exploitation, by any state or federal agency pursuant to an investigation conducted in accordance with Title 42 of the United State Code, Section 1935i-3(g)(1)(c) or 1396r(g)(1)(c), or Section 1-1950.7 or 1-1951 Title 63 of Oklahoma Statutes.I am not entered on the community services worker registry pursuant to Section 1025.3 of Title 56 of the Oklahoma Statutes.I am not recorded on the Child Care Restricted Registry pursuant to Section 405.3 of Title 10 of the Oklahoma Statutes.I am not registered pursuant to the Sex Offenders Registration Act, the Mary Rippy Violent Crime Offenders Registration Act, or registered on another state's sex offender registry;

Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(L2), by my signature below I affirm and agree to the following:

a.I am not disqualified based on the disqualifying criteria listed above,

b. I agree that, if the information in the registry screening and criminal history record check confirms that I am disqualified based on disqualifying criteria listed above, my employment, independent contract, or clinical privileges will be terminated unless and until I have appealed the determination and can provide that the information is incorrect, and

C. I understand that false statements about disqualifying criteria will result in the termination of my employment, independent contract, or clinical privileges, and that those conditions are good cause for termination.

Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(N), The period of provisional employment shall not exceed sixty (60) days pending the completion of the required background check. During this time the employee shall be subject to direct on-site supervision. The sixty-day time period may only be extended for those employees who are appealing the results of the background check. The time period shall only be extended for the duration of the appeal.

Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(O), an individual who knowingly provides false information regarding his or her identity, criminal convictions, or substantiated findings on a statement described in subparagraph a of paragraph 2 of subsection L of this section is guilty of a misdemeanor punishable by a fine of not less than One Hundred Dollars ($100.00) nor more than Three Hundred Dollars ($300.00), imprisonment in the county jail for not more than thirty (30) days, or by both such fine and imprisonment.

My signature acknowledges that I have read, understand and accept the terms and conditions outlined on this form.

Printed Name of Applicant*

Signature of Applicant*

Date