Odh Form 805 - Uniform Employment Application For Nurse Aide Staff (Page 3 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 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

3. Disposition of complaint; e.g., “dismissed insufficient evidence”

4. Date of disposition

5. Copies of any correspondence received by applicant with regard to the complaint

1. ______ Yes ______ No

Have you ever been arrested, charged with, entered a plea of guilty, no contest, convicted of or

been sentenced for any criminal offense in any state or US jurisdiction?

____________________________________________________________________________________________________________

2. ______ Yes ______ No

Have you ever been found to have violated any state, US jurisdiction or federal law regulating the

practice of a health care profession?

____________________________________________________________________________________________________________

3. ______ 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?

____________________________________________________________________________________________________________

Oklahoma State Department of Health

ODH Form 805

Protective Health Services

Revised 07/08

Odh Form 805 - Uniform Employment Application For Nurse Aide Staff Page 3

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