Wichita Falls/Vernon

In making application for employment: I certify that the information in this application is true and complete for all practical purposes. It may be verified bythe Hospice 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 Hospice or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate termination without recourse. I understand and agree that if I am offered employment by the Hospice, my employment will be for no definite term and that either I, or the Hospice 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 Hospice. I understand, if I am applying for a position that will have direct patient contact that the Hospice will perform a background check, including name and DOB based criminal history check (Name-based information is not an exact search, only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed on my own accord, to clear any misidentification based on the result of the name and DOB search), OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Hospice will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there’s a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, without holding them liable for any accurately released information, and also authorize the Registrar / enrollment or admissions 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 license status and my license history.