Employment

Home About us

    EMERALD CARE CENTER

    EMPLOYMENT APPLICATION

    DIRECTIONS: Respond to ALL questions. If a particular question does not apply to you, or the position for which you are applying, write N/A In the appropriate blank. PLEASE PRINT CLEARLY. Incomplete applications will not be considered.

    EQUAL OPPORTUNITY EMPLOYER: Emerald Care Center. will not discriminate against any employee or applicant for employment because of race, color, religion, sex, age, national origin, ancestry, citizenship status, disability, handicap or any other legally protected category. Any information received about the applicant will not be used for impermissible purposes.

     

    PERSONAL

    Are employment records pertaining to you kept under any other name? If yes, give full name.
    YesNo

     

    POSITION DESIRED

    Shift(s) Preferred: DayEveningNightAll

    Days Preferred: SunMonTuesWedThursFriSat

    Salary Expected

     

    Full-TimePart-TimePRN/per diemTemporary

    Are you willing to work weekends? YesNo

     

    LICENSE OR CERTIFICATION

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

     

    EDUCATION

    Course of Study

    Circle last year of school completed:
    1 2 3 4 5 6 7 8 9 10 11 12

    College:
    1 2 3 4 5 6 7 8

    Nursing:
    1 2 3 4

    Business or Trade:
    1 2 3 4

    High School

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

    College or Nursing

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

    Business or Trade

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

     
     

    Please check the box that best describes your attendance at your most recent place of employment.

    Position Title

    Approx. Dates

     

    Supervisor

    Reason for Leaving

     

    WORK HISTORY (This section of the application must be completed even if a resume is submitted.)

    Please Ilst the name(s) of present and previous employers in order, beginning with the most recent employer. Include periods of Uniformed Service, self-employment and unemployment. Attach additional sheets if necessary.

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

    May we contact your present employer. NoYes

    Signature (Incomplete applications will not be considered)

    NOTICE: I understand that this employment application and any other Company documents are not contracts of employment, express or implied, and that if hired, t may voluntarily leave employment, or may be terminated by the Company at any time and for any or no reason, with or without cause. I understand that any oral or written statements to the contrary are hereby expressly disavowed and will not be relied upon by me. I give the Company and its agents permission to enter the information "rrs`';d0 ^n th,c application into electronic information systems used by the Company. The information given by me is certified to be true and complete for all practical purposes and it may be verified by Emerald Care Center Should a position be offered and later it is found that the information is untrue, incomplete or misrepresented, I understand and agree that 'Emerald Care ceder. is relieved of all commitments, financial or otherwise, pertinent to employment, and that I am subject to immediate discharge without recourse. I also understand that I may be offered employment ...:011ditioned on my successfully passing criminal and/or other background checks and/or drug test and/or physical exam to the satisfaction of the Company.

    Are you authorized (i.e. Social Security card or work visa) to work in the
    United States?   NoYes

    If yes, can you submit verification of your legal right to work in the United States if offered a position?   NoYes

    Signature of Applicant

    Date

     

    EMERALD CARE CENTER is required by law to ask the following questions and may be required by law to report the answers to governmental agencies responsible for supervising health care, nursing home, home care and/or hospice care activity:

    1. Have you ever been convicted and/or been found guilty by a court of competent jurisdiction or a state agency of abusing, neglecting or rnistreating residents or of misappropriating resident property in this state or in any other state? If so, please describe the offense, the date and place of the conviction, and the underlying circumstances or other information to help us evaluate your current fitness for employrnent.    NoYes

    Explain

    2. Have you ever been convicted of a felony? If so, please describe the offense, the date of the conviction and the underlying circumstances or other inforrnation to help us evaluate your current fitness for employment.    NoYes

    Explain

    3. Have you ever been convicted of (1) cruelty to persons or (2) assault of a victim 60 years of age or side/it so, please describe the offense, the date of the conviction and the underlying circumstances or other information to help us evaluate your current fitness for employment.    NoYes

    Explain

    4. Have you ever been sanctioned by a health care licensing agency in this or any other state, or in any other United States or foreign jurisdiction? If so, please identify the nature and date of the action, the licensing agency involved and the underlying circumstances or other information to help us evaluate your current fitness for employment.    NoYes

    Explain

    "I hereby certify that have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of rnisappropriation of resident or patient property in this state or in any state, and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer of employment that is extended to me by Emer. Care cen. is conditional upon the verification of this information with the state patient abuse registry ana tn. a listing in such registry or the registry of any other state may act as an automatic withdrawal of any such offer of employment"

    i further understand that if I'm applying fora licensed or certified position, any offer of employment by
    is conditional upon verification of my license or certification with the appropriate sta. agency. In the event that I have not yet been so licensed or certified and in the event that I am offered employment witherner. Care Center, I agree to undertake the required training and competency certification requirements immediately upon commei.ing employment"

    PLEASE SEE REVERSE SIDE OF THIS PAGE FOR IMPORTANT INFORMATION

     

    INVESTIGATION INFORMATION RELEASE AUTHORIZATION

    I understand that EMERALD CARE CENTER requires a thorough pre-employment background investigation. This investigation is limited to only that information required to determine fitness for employment and may include, but is not limited to: employment history verification, job performance, disciplinary record, financial/credit history and a criminal background investigation. By signing this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this Authorization.

      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. § 1-1950.4, Uniform Employment Application for Nurse Aide Staff- Purpose - Training. The content of this form shall not be altered.

      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.
        1. 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.
          1. 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).
          2. Program Name: List the title of the training program where the training was received.
          3. 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 1-1950.1(C) states: Oklahoma State :
       

      §63-1-1950.1. Definitions - Criminal arrest check on certain persons offered employment -Exemptions.

      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:

      1. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person
      2. rape, incest or sodomy
      3. child abuse
      4. murder or attempted murder
      5. manslaughter
      6. kidnapping
      7. aggravated assault and battery
      8. assault and battery with a dangerous weapon, or
      9. arson in the first degree.

      2. If less than seven (7) years have elapsed since the completion of sentence, 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:

      1. assault
      2. battery
      3. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender
      4. pandering
      5. burglary in the first or second degree
      6. robbery in the first or second degree
      7. robbery or attempted robbery with a dangerous weapon, or imitation firearm
      8. arson in the second degree
      9. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V dnig as defined by the Uniform Controlled Dangerous Substances Act
      10. grand larceny, or
      11. 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.

      Pursuant to 63 O.S. 1-1950. 1(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any tearm that is deferred, suspended, suspended or subject to parole.

       

      Uniform Employment Application for Nurse Aide Staff

      Effective November 1, 2012

      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, continuuin of care facilities, hospice programs, adult day care centers and home care agencies.

      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

      List any other name(s) you have previously worked under, such as maiden name:

      Present Address:

       

       

       

      Permanent Address (if different than present address):

       

       

       

      Race

      For purposes of Criminal History Records Search

       

      2. Employment Desired

      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

       

      Employer's Name:

      Employer's Address:

      Street:

      City

      State:

      Zip:

      Supervisor:

      Reason for Leaving:


      Employer's Name:

      Employer's Address:

      Street:

      City

      State:

      Zip:

      Supervisor:

      Reason for Leaving:


      Employer's Name:

      Employer's Address:

      Street:

      City

      State:

      Zip:

      Supervisor:

      Reason for Leaving:


      List name(s) of all other employers for the last five (5) years:
      YesNoNot applicable

      Have you ever been terminated or asked to resign from any position?
      YesNo

      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.

      Name of Institution (High School, Technical School, College)

      Type of Studies

      Dates Attended & Diplomas, etc.

      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:

      Certified Medication Aide-Gastrostomy (CMA-G)

      Certified Medication Aide-Glucose Monitoring (CMA-GM)

      Certified Medication Aide-Respiratory (CMA-R)

      Certified Medication Aide-Insulin Administration (CMA-I A)

      List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed:


      I f you are a CMA, have you obtained your 8 hours of continuing education for the current 12-month certification period before your certification expires?
      YesNo


      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. YesNo Have you ever: I ) 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. YesNo Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the
      practice of a health care profession?


      c. YesNo 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?


      c. YesNo 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. YesNo I understand the employer has the right to proceed with any criminal background check.


      b. YesNo 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 anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. If 1 refuse to sign this form and submit to drug testing, the employer will reject my application.


      c. YesNo I 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. YesNo I 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. YesNo I 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 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 * * *

      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

      Data of signature

      12. Criminal Arrest Check List
      Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered if the below signed individual 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, as stated by Oklahoma Statute, Section 1-1950.1(C)(1) of Title 63:

      1. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
      2. rape, incest or sodomy,
      3. child abuse,
      4. murder or attempted murder,
      1. manslaughter,
      2. kidnapping,
      3. aggravated assault and battery,
      4. assault and battery with a dangerous weapon, or
      5. arson in the first degree.

      Effective November I, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered for the below signed individual if less than seven (7) years have elapsed since the completion of sentence, 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, as stated by Oklahoma Statute, Section 1-1950.1(C)(2) of Title 63:

      1. assault,
      2. battery,
      3. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
      4. pandering,
      5. burglary in the first or second degree,
      6. robbery in the first or second degree,
      1. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
      2. arson in the second degree,
      3. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
      4. grand larceny, or
      5. petit larceny or shoplifting.

      Pursuant to 63 O.S. § 1-1950.1(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole.
      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.

      Pursuant to 63 O.S. § 1-1950.1(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole.
      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.