Odh Form 805 - Uniform Employment Application For Nurse Aide Staff (Page 4 of 7) in pdf

Uniform Employment Application for Nurse Aide Staff

Background Information (Continued)

4. ______ 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?

____________________________________________________________________________________________________________

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.

1. ______ Yes ______ No

I understand that the employer has the right to proceed with any criminal background check.

____________________________________________________________________________________________________________

2. ______ Yes ______ No

I understand that 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.

____________________________________________________________________________________________________________

3. ______ Yes ______ No

I understand that 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.

____________________________________________________________________________________________________________

4. ______ Yes ______ No

I understand that 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.

____________________________________________________________________________________________________________

5. ______ Yes ______ No

I understand that this form is not an employment contract.

____________________________________________________________________________________________________________

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: ________________________________________________ Number of Training Days: _______

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 4