In the ever-evolving landscape of healthcare employment, the introduction of the ODH 805 form on November 1, 2012, marked a significant stride towards standardizing the hiring process for nurse aide staff across various healthcare settings. Mandated by Title 63 O.S. § 1-1950.4, this comprehensive form serves as the sole application for nurse aide positions 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. Designed to streamline the application process, the form covers essential areas such as personal information, employment desired, U.S. military record, prior work history, educational background, certifications, references, and critical background information. Additionally, it emphasizes the importance of criminal background checks in alignment with public law requirements, ensuring the safety and well-being of patients. Notably, the form adheres to non-discrimination policies based on race, color, sex, religion, citizenship, national origin, veteran status, age, or disabilities, as per the Americans with Disabilities Act (ADA), highlighting the inclusive approach towards hiring. With its detailed structure, the ODH 805 form functions not just as an application but as a tool ensuring regulatory compliance and facilitating a thorough vetting process for healthcare providers seeking to hire nurse aides.
| Question | Answer |
|---|---|
| Form Name | Odh 805 Form |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | oklahoma odh form employment, atf etrace pdf fillable, oklahoma uniform employment application, oklahoma 805 |
Effective November 1, 2012
Employer Instructions for Use – ODH Form 805
Uniform Employment Application for Nurse Aide Staff
Purpose
This form is to be used by employers as the only employment application for hiring nurse aide staff 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 as mandated by Title 63 O.S. §
Employer Instructions
Provide this form to all applicants seeking employment as a nurse aide. The form may be duplicated as needed.
Instruct the applicant to complete each section of this form.
1.Personal Information
2.Employment Desired
3.U.S. Military Record
4.Prior Work History
5.Educational Background
6.Certification
7.References
8.Background Information
9.Applicant‟s Certification and Agreement
10.Previous CNA Training: If the applicant will require nurse aide training, instruct to complete section 10 on page 4.
NOTE: If the facility has an approved nurse aide temporary emergency waiver, the applicant must be trained and certified within four (4) months of hire date.
Category: List any CNA training received in the past by type of training: Long Term Care Aide (LTCA), Home Health Aide (HHA), Adult Day Care Aide (ADCA), Residential Care Aide (RCA) and Developmentally Disabled Direct Care Aide (DDDCA).
Program Name: List the title of the training program where the training was received.
Training Days: List the number of days of training completed for each category.
11.Important Information for the Job Applicant
Instruct applicant to read and initial in the gray „NOTICE‟ box on page 5, then sign and date certifying the application is true and complete.
12.Criminal Arrest Check
Instruct the applicant to read and complete the „Criminal Arrest Check List‟ section on page 5. Obtain the applicant‟s signature and date in the designated spaces.
Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
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Revised 10/19/2012 |
Employer Instructions for Use – Uniform Employment Application for Nurse Aide Staff
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C. 1. If the results of a criminal history background check reveal that the subject person has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, the employer shall not hire or contract with the person:
a. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
b. rape, incest or sodomy, c. child abuse,
d. murder or attempted murder,
e.manslaughter,
f.kidnapping,
g.aggravated assault and battery,
h.assault and battery with a dangerous weapon, or
i.arson in the first degree.
2.If less than seven (7) years have elapsed since the completion of sentence1, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, the employer shall not hire or contract with the person:
a.assault,
b.battery,
c.indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
d.pandering,
e.burglary in the first or second degree,
f.robbery in the first or second degree,
g.robbery or attempted robbery with a dangerous weapon, or imitation firearm,
h.arson in the second degree,
i.unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
j.grand larceny, or
k.petit larceny or shoplifting.
Information regarding ADA requirements
The employer will note there is no information requested on the ODH Form 805, Uniform Employment Application for Nurse Aide Staff, pertaining to the Americans with Disabilities Act (ADA). However, it should be noted that any qualified applicant with a disability may request reasonable accommodation(s) to complete the application/interview process. The specific nature of the accommodation and the reason for the
request must be indicated at the time the application is requested. All other ADA requirements related to the hiring process must be met according to the employer‟s procedure and be in compliance with the ADA.
1Pursuant to 63 O.S. §
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
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Revised 10/19/2012 |
Uniform Employment Application |
Effective November 1, 2012 |
for Nurse Aide Staff |
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This application form is required by Title 63 O.S. §
This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race,
color, sex, 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.
ATTENTION NURSE AIDES: RETURN YOUR COMPLETED APPLICATION TO EMPLOYER.
Date of Application: _________________ |
Date Available to Start Work: _________________ |
1.Personal Information
Name: ____________________________________________________________ Social Security Number:_____________________
(Last) |
(First) |
(Middle) |
List any other name(s) you have previously worked under, such as maiden name:_____________________, _____________________
___________________________, __________________________, __________________________, __________________________
Present Address:______________________________________________________________________________________________
(Street)(City)(State)(Zip)
Permanent Address (if different than present address): _____________________________________________________________________
(Street)(City)(State)(Zip)
Telephone #: ___________________ Date of Birth: _______________ Sex: ____ M ____ F Race: ________________________
Emergency Contact Person: _____________________________________________________________________________________
(Name) |
(Address) |
(Phone Number) |
2.Employment Desired
Position applied for: ____________________________________________________________ Salary required: _________________
Hours available to work: ______ Days ______ Evenings _____ Nights _____Weekends
Will you accept employment of: ______ Full Time? ______ Part Time? _____ Occasional Part Time?
3.U.S. Military Record
Branch: ____________________ Date Entered: ___________ Date Discharged: ___________ Type of Discharge: _______________
4.Prior Work History List your last four (4) jobs beginning with your most recent or current employer.
Employer‟s Name:__________________________________________________________ Telephone Number: _________________
Employer‟s Address: __________________________________________________________________________________________
(Street)(City)(State)(Zip)
Position Held: ______________________________ Supervisor: _______________________________________________________
Dates Employed: From (month/year) ________________ To (month/year) ________________ Salary: _______________________
Reason for Leaving: ___________________________________________________________________________________________
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
Page 1 of 5 |
Revised 10/19/2012 |
Uniform Employment Application for Nurse Aide Staff
Employer‟s Name:__________________________________________________________ Telephone Number: _________________
Employer‟s Address: __________________________________________________________________________________________
(Street)(City)(State)(Zip)
Position Held: ______________________________ Supervisor: _______________________________________________________
Dates Employed: From (month/year) ________________ To (month/year) ________________ Salary: _______________________
Reason for Leaving: ___________________________________________________________________________________________
Employer‟s Name:__________________________________________________________ Telephone Number: _________________
Employer‟s Address: __________________________________________________________________________________________
(Street)(City)(State)(Zip)
Position Held: ______________________________ Supervisor: _______________________________________________________
Dates Employed: From (month/year) ________________ To (month/year) ________________ Salary: _______________________
Reason for Leaving: ___________________________________________________________________________________________
Employer‟s Name:__________________________________________________________ Telephone Number: _________________
Employer‟s Address: __________________________________________________________________________________________
(Street)(City)(State)(Zip)
Position Held: ______________________________ Supervisor: _______________________________________________________
Dates Employed: From (month/year) ________________ To (month/year) ________________ Salary: _______________________
Reason for Leaving: ___________________________________________________________________________________________
List name(s) of all other employers for the last five (5) years:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
May we contact your present employer? ______ Yes ______ No ______ Not applicable
Have you ever been terminated or asked to resign from any position? ______ Yes ______ No
If yes, provide reason. ______________________________________________________________________________________
5.Educational Background List all educational schools attended with degrees, diplomas or certificates received.
Name of Institution (High School, Technical School, College)
Type of Studies
Dates Attended & Diplomas, etc.
If your school or employment records are under another name(s), indicate that name(s): _____________________________________
6.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 |
______ Certified Medication |
||
______ Certified Medication |
______ Certified Medication |
||
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
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Uniform Employment Application for Nurse Aide Staff
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
If yes, where and when did you obtain. _____________________________________________________________________
7.References List name, address and telephone number of three (3) references who are not relatives or former employers.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
8.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/offense.
3.Disposition of complaint and/or offense (e.g., “dismissed insufficient evidence”, “deferred sentence”).
4.Date of disposition.
5.Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.
a. ______ Yes ______ No 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?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
b. ______ 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? |
|
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
c. ______ 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? |
|
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
d. ______ 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?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
9. 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.
a. ______ Yes ______ NoI understand the employer has the right to proceed with any criminal background check.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
Page 3 of 5 |
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Uniform Employment Application for Nurse Aide Staff
b. ______ Yes ______ NoI understand as a part of the job selection process, I may be required to take a
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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
c. ______ Yes ______ NoI understand 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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
d. ______ Yes ______ NoI understand 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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
e. ______ Yes ______ NoI understand this form is not an employment contract.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
10. 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 ______________________________________________ Start Date __________ End Date __________
Category______ Program Name ______________________________________________ Start Date __________ End Date __________
Category______ Program Name ______________________________________________ Start Date __________ End Date __________
11.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
* * * 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 NONRENEWAL 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.
INITIAL HERE_______
I certify I have read and completed this application and that the information I have provided on this application is true and complete.
____________________________________________________ |
____________________________ |
Signature of Applicant |
Date of Signature |
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
Page 4 of 5 |
Revised 10/19/2012 |
Uniform Employment Application for Nurse Aide Staff
12.Criminal Arrest Check List
Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section
a. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
b.rape, incest or sodomy,
c.child abuse,
d.murder or attempted murder,
e.manslaughter,
f.kidnapping,
g.aggravated assault and battery,
h.assault and battery with a dangerous weapon, or
i.arson in the first degree.
Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section
a.assault,
b.battery,
c.indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
d.pandering,
e.burglary in the first or second degree,
f.robbery in the first or second degree,
g.robbery or attempted robbery with a dangerous weapon, or imitation firearm,
h.arson in the second degree,
i.unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
j.grand larceny, or
k.petit larceny or shoplifting.
1 Pursuant to 63 O.S. §
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 I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section
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 Investigation authority to
proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.1(B).
____________________________________________________ |
____________________________ |
Signature of Applicant |
Date of Signature |
Oklahoma State Department of Health |
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ODH Form 805 |
Protective Health Services |
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Revised 10/19/2012 |