Odh Form 805 - Uniform Employment Application For Nurse Aide Staff (Page 6 of 7) in pdf

Odh Form 805 - Uniform Employment Application For Nurse Aide Staff Page 6

PRE-EMPLOYMENT CRIMINAL HISTORY RELEASE

POLICY:

The facility may not employ individuals who have been convicted of abusing, neglecting, or

mistreating individuals. If an applicant for employment at St. Simeon's has been convicted of any of the following

offenses, the facility shall not hire the person according to the law:

A. Assault, battery or assault and battery with a dangerous weapon

B. Aggravated assault and battery

C. Murder or attempted murder

D. Manslaughter except involuntary manslaughter

E. Rape, incest or sodomy

F. Indecent exposure and indecent exhibition

G. Pandering

H. Child abuse

I. Abuse, neglect or financial exploitation of any person entrusted to his care or possession

J. Burglary in the first or second degree

K. Robbery in the first or second degree

L. Robbery or attempted robbery with a dangerous weapon, or imitation firearm

M. Arson in the first or second degree

N. Unlawful possession or distribution, or intent to distribute unlawfully, Schedule I through V drugs as defined by

the Uniform Controlled Dangerous Substance Act.

O. Grand larceny, or

P. Petit larceny or shoplifting within the past seven (7) years.

have read and understood the above information. I realize any employment

offered me will be pending results of the criminal arrest check that Saint Simeon's Episcopal Home is required by

law to conduct.

Date of Birth

Social Security No. ____________________

(Print Name) _______________________________________

(Signature) _________________________________________

(As requested by company doing the pre-employment criminal history.)

Odh Form 805 - Uniform Employment Application For Nurse Aide Staff Page 6