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Nursing Employment

This application form is required by Title 63 O.S. 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care facilities, hospice programs, adult day care centers and home care agencies.

This employer does not discriminate in its hiring decisions on in any other employment decision on the basis of race, color, gender, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant’s/employee’s ability to perform the essential functions of the position.

Employment Form

Nursing Aide Application

Date of Application *

Desired Starting Date *

Name (First, MI, Last) *

Address *

City *

State / Zip *

Phone Number *

Date of Birth *

Gender *

Male

Female

Race *

Emergency Contact Name, Number & Address *

Position Applied For? *

Available Working Hours *

Days

Evenings

Nights

Weekends

Check All That Apply

Employment Type *

Full Time

Part Time

Check All That Apply

U.S. Military Branch

Leave Blank If Not Applicable

U.S. Military Date Entered

Leave Blank If Not Applicable

U.S. Military Date Discharged

Leave Blank If Not Applicable

U.S. Military Discharge Type

Leave Blank If Not Applicable

Current or Previous Employer Name *

If Currently Unemployed, Type Unemployed

Current or Previous Employer Address *

If Currently Unemployed, Type Unemployed

Current or Previous Employer Phone *

If Currently Unemployed, Type Unemployed

Current or Previous Employer Supervisor *

If Currently Unemployed, Type Unemployed

Current or Previous Employer Position *

If Currently Unemployed, Type Unemployed

Current or Previous Employer Starting Date *

If Currently Unemployed, Type Unemployed

Current or Previous Employer End Date *

If Currently Unemployed, Type Unemployed

May We Contact Your Previous Employer? *

Yes

No

Have You Been Terminated or Asked To Resign From A Position? *

Yes

No

If Yes, Please Explain

List Name(s) Of All Other Employers For The Last Five (5) years *

List Educational Schools Attended & Dates *

Current Certifications As A Nurse Aide (CNA) *

Long Term Care (LTC)

Residential Care Aide (RCA)

Certified Medication Aide-Gastrostomy (CMA-G)

Certified Medication Aide-Respiratory (CMA-R)

Home Health Aide (HHA)

Developmental Disability Aide (DDA)

Adult Day Care (ADC)

Certified Medication Aide (CMA)

Certified Medication Aide-Glucode Monitoring (CMA-GM)

Certified Medication Aide-Insulin Administration (CMA-IA)

Check All That Apply

List All Technical Special Skills or Education Honors, Certifications, Licenses, Memberships or Medication Administration Technician (MAT) Certification Not Previously Listed *

Type N/A If Not Applicable

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 You Answered Yes Above, Where & When Did You Obtain? *

Type N/A If Not Applicable

Have You Ever: 1.) Participated In A First Offender Program; 2.) Deferred Adjudication or Other Program or Arrangement Where Adjudication Has Been Withheld; 3.) Pled Guilty or No Contest; 4.) Been Convicted; 5.) Received A Deferred Sentence; and/or 6.) Been Sentenced For Any Criminal Offense In Any State or US Jurisdiction Regardless Of Whether This Matter Has Been Expunged or Otherwise Removed? *

Yes

No

Have You Ever Been Found In Violation Of Any State, US Jurisdiction, or Federal Law Regulating The Practice Of A Health Care Profession? *

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 US Jurisdiction? *

Yes

No

Have You Had Any Certificate, License, Registration or Other Privilege To Practice A Health Care Profession Denied, Removed, Suspended, Restructed, 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? *

Yes

No

If You Answered Yes To Any of The Previous Questions, Please Explain. *

Type N/A If Not Applicable

I Understand The Employer Has The Right To Proceed With Any Criminal Background Check. *

Yes

No

I Understand 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 Any Time During My Employment. A Rest 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. *

Yes

No

I Understand I May Be Required To Have A Physical Examination And I Herby Consent To Take A Physical Examination And Any Future Physical Examinations As Required By The Employer. *

Yes

No

I Understand If I am Hired I Will Be Required To Produce Proof That I Have A Legal Right To Work In The USA In Accordance With The IRCA Of 1986. *

Yes

No

I Understand This Application Is Not An Employment Contract. *

Yes

No

If You Answered No To Any of The Previous Questions, Please Explain. *

Type N/A If Not Applicable

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. *

NOTICE: By Typing Your Full Name Above, You Agree To This Notice. I Understand Providing False Or Misleading Information To A Training Program, A Facility, Or The Department Is Grounds For Denial, Suspension, Withdrawal, and/or Non-renewal Of Certification. I Also Understand Providing False Information or Omission Of Facts May Disqualify Me From Employment And May Cause Termination If Discovered At A Later Date. Click The Submit Button To Send This Form.

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