Form 805 - Uniform Employment Application For Nurse Aide Staff Page 6
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7Uniform Employment Application for Nurse Aide Staff
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.
a. ______ Yes ______ No
I understand the employer has the right to proceed with any criminal background check.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
b. ______ Yes ______ No
I understand as a part of the job selection process, I may be required to take a drug-screening test
at the time of employment and if requested in accordance with the state and federal law at anytime
during my employment. A test result that has been confirmed as positive will eliminate me from
employment. If I refuse to sign this form and submit to drug testing, the employer will reject my
application.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
c. ______ Yes ______ No
I understand I may be required to have a physical examination and I hereby consent to take a
physical examination and any future physical examinations as required by the employer.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
d. ______ Yes ______ No
I understand if I am hired I will be required to produce proof that I have a legal right to work in the
U.S.A. in accordance with the IRCA of 1986.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
e. ______ Yes ______ No
I understand this form is not an employment contract.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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.
Category______ Program Name ______________________________________________ Start Date __________ End Date
__________
Category
______ Program Name ______________________________________________ Start Date __________ End Date
__________
Category
______ Program Name ______________________________________________ Start Date __________ End Date __________
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.
INITIAL HERE
_______
Oklahoma State Department of Health
ODH Form 805
Protective Health Services
Page 4 of 5
Revised 01/2011
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