Attendant Employment Application

First Name

Last Name

Social Security Numer Name

Present PHYSICAL Address
	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Present MAILING Address
	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands

Phone Number

Alternate Phone Number

Are you at least 18 years old?   YesNo

If you are not a US Citizen, have you the legal right to remain permanently in the US?   YesNo

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?   YesNo

If YES, please give, date place and nature of each such conviction

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Are you presently charged with any violation of the law other than traffic violation?   YesNo

If YES, please give, date place and nature of each such conviction

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Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?   YesNo

Position Applying for

Shift: Full TimePart TimeTemporaryDayNightEveningWeekend

Expected rate of pay

Date Available

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EDUCATIONAL HISTORY

List any professional licenses you possess. Indicate type of license, number and state.

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin or disability.

List languages spoken other than English:

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:

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PERSONAL REFERENCES

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EMPLOYMENT HISTORY
Begin with current or most recent employer

Dates  from	to	Employer
City/State	Rate of Pay	Job Title
Inmediate Supervisor	Reason for Leaving	May we contact?YesNo
Phone Number		Fax

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Dates  from	to	Employer
City/State	Rate of Pay	Job Title
Inmediate Supervisor	Reason for Leaving	May we contact?YesNo
Phone Number		Fax

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Dates  from	to	Employer
City/State	Rate of Pay	Job Title
Inmediate Supervisor	Reason for Leaving	May we contact?YesNo
Phone Number		Fax

 

Name

Relationship

Telephone

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STATEMENT OF CERTIFICATION

I hereby certify that this application contains no willful misrepresentation or falsification and that the information given by me is true and correct to the best of my knowledge. I understand that should the investigation reveal a misrepresentation or falsification, such findings could result in rejection of an application or in immediate termination of employment.

I authorize all previous employers and current employers to give any and all information concerning my employment and other pertinent information they may have, personal or otherwise, to this company and release all parties from any damages which may result from the furnishing of such information. I understand and agree that if hired my employment is for no definite period of time and that I may, regardless of the date of payment of any wages or salary be terminated at any time without prior notice.

I also understand that if hired, I am not to lift or transfer any object or patient by myself, unless I am familiar with the given situation and am reasonably sure that I could accomplish this without injuring myself or the patient.

If I am accepted for employment with this company, I agree to abide by its personnel policies and also to report to my supervisor any and all job-related injuries and illnesses within twenty-four (24) hours of their occurrence, regardless of severity. I understand that this employer DOES NOT SUBSCRIBE TO WORKER'S COMPENSATION INSURANCE where it is not required, and that my failure to report any injury within twenty-four (24) hours may cause this employer not to render any voluntary payments of claims arising from injury.

WORKER'S COMPENSATION

NON-COVERAGE:
THE AGENCY DOES NOT have worker's compensation insurance coverage to protect you from damages resulting from a work related injury or illness. However, you may have rights under the common law of Texas. Your employer is required to provide you with coverage information when you are hired or whenever the employer becomes, or ceases to be, covered by workers' compensation insurance.

SAFETY HOTLINE:
The Commission has established a 24 hour toll free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact the Division of Worker's Health & Safety at 1-800 452-9595.

EQUAL EMPLOYMENT OPPORTUNITY

The agency is in accordance with The Americans with Disabilities Act (ADA) which prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communications, and governmental activities; The Age Discrimination in Employment Act of 1967 (ADEA) protects certain applicants and employees 40 years of age and older from discrimination on the basis of age in hiring, promotion, discharge, compensation, or terms, conditions or privileges of employment. The ADEA is enforced by the Equal Employment Opportunity Commission (EEOC); Title VII of the Civil Rights Act of 1964, prohibits employment discrimination based on race, color, religion, sex and national origin, Office of Federal Contract Compliance Programs (OFCCP) which promotes equal employment opportunity on behalf of qualified special disabled veterans, Vietnam era veterans, recently separated veterans, and veterans who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

AFFIDAVIT OF CRIMINAL HISTORY

I FULLY UNDERSTAND that this employer is REQUIRED BY LAW to CHECK CRIMINAL RECORDS. I UNDERSTAND that this agency must obtain my criminal history information before an offer of employment would be made, and that all information will remain confidential. I have read and understand these conditions. I have informed the company of all the names (e.g., maiden, aliases, etc.) that I have used in the past. Convictions, which may bar my employment, are listed below and may not be all inclusive: Aggravated Robbery, Agreement to Abduct from Custody, Arson, Assaultive Offenses, Burglary and Criminal Homicide, Fraud, Illegal Possession or Distribution of a controlled substance, Indecency with a child, Indecent exposure, Kidnapping/False Imprisonment, Public Indecency, Public Lewdness, Robbery, Sale or Purchase of a child, Solicitation of a child, Theft, Weapons.

Signature		Agency Representative Signature
		Date: ____/____/____/

STATEMENT OF EMPLOYABILITY

By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed in the NAR or EMR per TAC 893.3 and TxH&SC Chapter 253.

Criminal History Check I have informed this Agency of all names (i.e. maiden name, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check and that I may not have face-to-face patient contact until results are returned. I will be notified of results. Convictions Barring Employment

(A) A person for whom the facility or the individual employer is entitled to obtain criminal history record information may not be
employed in a facility or by an individual employer if the person has been convicted of an offense listed below in this subsection:

• An offense under Chapter 15.01, Penal Code (criminal attempt of any offense listed as a bar);

• An offense under Chapter 43.03, Penal Code (promotion of prostitution);

• An offense under Chapter 43.04, Penal Code (aggravated promotion of prostitution);

• An offense under Chapter 43.05, Penal Code (compelling prostitution);

• An offense under Chapter 43.25, Penal Code (sexual performance by a child);

• An offense under Chapter 43.26, Penal Code (possession or promotion of child pornography);

• An offense under Chapter 19, Penal Code (criminal homicide);

• An offense under Chapter 20, Penal Code (kidnapping and unlawful restraint and smuggling of persons);

• An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children), or Section 21.11, Penal Code
  (indecency with a child);

• An offense under Section 22.011, Penal Code (sexual assault);

• An offense under Section 22.02, Penal Code (aggravated assault);

• An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);

• An offense under Section 22.041, Penal Code (abandoning or endangering a child);

• An offense under Section 22.08, Penal Code (aiding suicide);
  • An offense under Section 25.031, Penal Code (agreement to abduct from custody);

• An offense under Section 25.08, Penal Code (sale or purchase of a child);

• An offense under Section 28.02, Penal Code (arson);

• An offense under Section 29.02, Penal Code (robbery);

• An offense under Section 29.03, Penal Code (aggravated robbery);

• An offense under Section 21.08, Penal Code (indecent exposure);

• An offense under Section 21.12, Penal Code (improper relationship between educator and student);

• An offense under Section 21.15, Penal Code (improper photography or visual recording);

• An offense under Section 22.05, Penal Code (deadly conduct);

• An offense under Section 22.021, Penal Code (aggravated sexual assault);

• An offense under Section 22.07, Penal Code (terroristic threat);

• An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);

• An offense under Section 33.021, Penal Code (online solicitation of a minor);

• An offense under Section 34.02, Penal Code (money laundering);

• An offense under Section 35A.02, Penal Code (Medicaid fraud);

• An offense under Section 36.06, Penal Code (obstruction or retaliation);

• An offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to non livestock animals); or

• A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

(B) A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be
employed by an individual employer before the fifth anniversary of the date the person is convicted of:

• An offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;

• An offense under Section 30.02, Penal Code (burglary);

• An offense under Chapter 31, Penal Code (theft), that is punishable as a felony;

• An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;

• An offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;

• An offense under Section 37.12, Penal Code (false identification as peace officer; misrepresentation of property); or

• An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).

(C) In addition to the prohibitions on employment described by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:

• Of an offense under Section 30.02, Penal Code (burglary); or

• Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code (burglary).

(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Article 42A.111, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

(E) In addition to the prohibitions on employment described by Subsections (A), (B) and (C), a nurse aide listed as unemployable per amendment to TAC 40 $94.10 (1) and 594.11(c)(d) and is listed on the NAR or EMR stating a finding of abuse, neglect or misappropriation will not be recertified therefore, is unemployable.

(F) Bars pursuant to TAC 40, Part 1, Chapter 3, $3.201, Chapter 481 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 481 of if the person has been convicted:

• Texas Controlled Substances Act: a conviction that is punishable as a felony (involving manufacture, delivery, intent to distribute, conspiracy to possess or produce with intent to distribute, distribution to minor, illegal expenditure or investment, or transfer or receipt of chemical laboratory apparatus).

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

Criminal History CheckEmployee Misconduct Registry (EMR)Nurse Aide Registry (NAR)Office Inspector GeneralE-Verify * Check online On Hire & Annually

https://records.txdps.state.tx.us/DpsWebsite/CriminalHistory/ https://emr.dads.state.tx.us/DadsEMRWeb/ https://emr.dads.state.tx.us/DadsEMRWeb/ https://exclusions.oig.hhs.gov/ https://e-verify.uscis.gov/enroll/StartPage.aspx?JS=YES

Comments to support hiring if other convictions found

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AUTHORIZATION FOR EMPLOYEE I NURSE AIDE MISCONDUCT REGISTRY CHECKS

An Applicant/ Employee may not be employed by this Agency if their name is listed on the Employee Misconduct Regist1y and the Texas Department of Human Services Nurse Aide Registry.

To search the Employee Misconduct Registry/ Nurse Aide Registry, this agency will call the Depa1tment of Human Services Toll Free Number (800) 452-3934 to verify an applicant is not listed as having committed an act that constitutes Reportable Conduct as defined by Health and Safety Code, §48.40 I, and any rules that further define "reportable conduct" as allowed by Health Safety Code, § 48.402.

Reportable Conduct (Complaint Hotline-1-800-458-9858)

• abuse or neglect that causes death or harm to an individual receiving agency services or a resident or consumer of a facility;

• sexual abuse of an individual receiving agency services or a resident or consumer of a facility;

• financial exploitation of an individual receiving agency services or a resident or consumer of a facility in an amount of $25 or more;

• emotional, verbal, or psychological abuse that causes harm to an individual receiving agency services or a resident or consumer of a facility.

I authorize THE AGENCY to conduct searches and checks on the Employee Misconduct Registry and the Texas Department of Human Services Nurse Aide Registry to determine my employability.

Name:
SSN:
Date: