Odh Form 805 - Uniform Employment Application For Nurse Aide Staff Page 5
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7Uniform Employment Application for Nurse Aide Staff
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.
I certify that the information provided on this application is true and complete. I understand that false information or
omission of facts may disqualify me from employment and may cause termination if discovered at a later date. In
addition, I could be fined up to $500 and or imprisonment up to one year.
____________________________________________________
____________________________
Signature of Applicant
Date of Signature
Criminal Arrest Check List
Employment at this employer shall not be considered if the below signed individual has been convicted of one of the
following crimes 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
battery with a dangerous weapon
entrusted to his care or possession
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 that I have no previous convictions as listed in the Oklahoma Statute, Section 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 Investigations 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
5
Protective Health Services
Revised 07/08
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