We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient.
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I certify that the information in this application is true and complete for all practical purposes. It may be verified by the Agency or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the Agency or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate termination without recourse.
I understand and agree that if I am offered employment by the Agency, my employment will be for no definite term and that either I, or the Agency will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the Agency.
I understand, if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHSregulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment.
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar / Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. I understand that this information may be released to patients/clients of the requesting company and other requesting third parties on a need-to-know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.
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 per Texas H&SC 250.006. 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. As required, I agree to a search of the Texas Health and Human Services Commission's OIG List of Excluded Individual/Entities, prior to being hired and monthly thereafter, the HHS - OIG Excluded Individuals/Entities Search Database. 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 as unemployable in the NAR or EMR per ТАC 26 ТAC Chapter 561, §561.3 and Texas H&SC Chapter 253.
Criminal History Check
I have informed the Agency of all names (i.e., maiden, 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/client contact until results are returned. I will be notified of results.
I acknowledge that if I am found to have been convicted of any offense(s) barring employment, that these offenses may bar my employment. I understand that all information obtained by the 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.
For Agency Use Only: Criminal history, Employee Misconduct Registry (EMR), Nurse Aide Registry (NAR), and OIG Exclusion Lists checks completed, as applicable. Attach state-specific background check policy regarding convictions barring employment.