Form 805 - Uniform Employment Application For Nurse Aide Staff

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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, 2010, and in accordance with public law, Title 63 of the Oklahoma Statutes,
Section 1-1950.1 states:
Oklahoma State Department of Health
ODH Form 805
Protective Health Services
i
Revised 01/2011

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