Form 805 - Uniform Employment Application For Nurse Aide Staff (Page 5 of 7) in pdf

Uniform Employment Application for Nurse Aide Staff

Certification

If you hold a current certification as a nurse aide (CNA), check the appropriate certification(s) below:

______ Long Term Care (LTC)

______ Home Health Aide (HHA)

______ Adult Day Care (ADC)

______ Residential Care Aide (RCA)

______ Developmental Disability Aide (DDA)

______ Certified Medication Aide (CMA)

______ Certified Medication Aide-Gastrostomy (CMA-G)

______ Certified Medication Aide-Glucose Monitoring (CMA-GM)

______ Certified Medication Aide-Respiratory (CMA-R)

______ Certified Medication Aide-Insulin Administration (CMA-IA)

List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician

(MAT) certification not previously listed: __________________________________________________________________________

____________________________________________________________________________________________________________

If you are a CMA, have you obtained your 8 hours of continuing education for the current 12-month certification period before your

certification expires? _____ Yes _____ No

If yes, where and when did you obtain. _____________________________________________________________________

References

(List name, address and telephone number of three (3) references who are not relatives or former employers.)

____________________________________________________________________________________________________________

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.

a. ______ Yes ______ No

Have you ever: 1) been arrested; 2) been charged; 3) pled guilty or no contest; 4) been convicted;

5) received a deferred sentence; and/or 6) been sentenced, for any criminal offense in any state or

US jurisdiction?

____________________________________________________________________________________________________________

b. ______ Yes ______ No

Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the

practice of a health care profession?

____________________________________________________________________________________________________________

c. ______ Yes ______ No

Are any disciplinary actions or allegations, pending or substantiated

, against you or your CNA

certification or health care professional license in any state or U.S. jurisdiction?

____________________________________________________________________________________________________________

d. ______ Yes ______ No

Have you had any certificate, license, registration or other privilege to practice a health care

profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation

by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such

credential to avoid, or in connection with, action by such authority?

____________________________________________________________________________________________________________

Oklahoma State Department of Health

ODH Form 805

Protective Health Services

Page 3 of 5

Revised 01/2011

Form 805 - Uniform Employment Application For Nurse Aide Staff Page 5

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