Form 805 - Uniform Employment Application For Nurse Aide Staff Page 7
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7Uniform Employment Application for Nurse Aide Staff
I certify I have read and completed this application and that the information I have provided on this application is
true and complete.
____________________________________________________
____________________________
Signature of Applicant
Date of Signature
12.
Criminal Arrest Check List
Employment at this employer shall not be considered if the below signed individual has been convicted of, pled guilty or
no contest to, or received a deferred sentence for any of the following offenses as stated by Oklahoma Statute, Section 1-
1950.1(F)(1) Title 63 (A through P of the list in this section):
A. Assault, battery, or assault and
I.
Abuse, neglect or financial exploitation of any person entrusted to
battery with a dangerous weapon,
the care or possession of such person,
B. Aggravated assault and battery,
J.
Burglary in the first or second degree,
C. Murder or attempted murder,
K. Robbery in the first or second degree,
D. Manslaughter, except involuntary manslaughter,
L. Robbery or attempted robbery with a dangerous weapon, or imitation
firearm,
E. Rape, incest or sodomy,
M. Arson in the first or second degree,
F. Indecent exposure and Indecent exhibition,
N. Unlawful possession or distribution, or intent to distribute unlawfully,
Schedule I through V drugs as defined by the Uniform Controlled
Dangerous Substance Act,
G. Pandering,
O. Grand larceny, or
H. Child abuse,
P. Petit larceny or shoplifting within the past seven (7) years.
It is further understood that if I am hired, it will be as a temporary employee until the employer receives my criminal
background check. If I have no criminal record in accordance with state law, I may be considered for employment,
subject to training requirements and other requirements of the job for which I am applying with this employer.
I hereby certify I have no previous convictions as listed in the Oklahoma Statute § 1-1950.1(F)(1) Title 63 (A
through P of the list in this section). My signature below authorizes the employer to run a check with the Nurse
Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of
resident’s property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with criminal
record history checks as required by law.
____________________________________________________
____________________________
Signature of Applicant
Date of Signature
Oklahoma State Department of Health
ODH Form 805
Protective Health Services
Page 5 of 5
Revised 01/2011
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