Careers at OKFDLooking for a job? Apply to work at OKFD!Please review job description (if applicable) and choose one of the 2 methods below to apply:1: You can fill out the form below and click submit. 2: You can download the pdf application, fill it out and email it to sross@okfd.org PDF Application 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 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. Personal Information Date of Application * MM DD YYYY Date Available to Start Work * MM DD YYYY Name * First Name Last Name Social Security Number (Last 4) List any other name(s) you have previously worked under, such as maiden name: Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth * MM DD YYYY Sex * Male Female Race * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Address * Employment Desired Position Applied For * Salary Required * Hours Available too Work * Days Evenings Nights Weekends Will you accept employment of * Full Time Part Time Occassional Part Time US Military Record Branch Date Entered * MM DD YYYY Date Discharged MM DD YYYY Type of Discharge Prior Work History List your last four (4) jobs beginning with your most recent or current employer Employer 1 * Employer's Phone # * (###) ### #### Employer's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held * Supervisor * Dates of Employment * Salary * Reason for Leaving * Employer 2 Employer's Phone (###) ### #### Employer's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held Supervisor Dates of Employment Salary Reason for Leaving Employer 3 Employer's Phone (###) ### #### Employer's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Held Supervisor Dates of Employment Salary Reason for Leaving List all other employers from the past 5 years May we contact your present employer? * Yes No Have you ever been terminated or asked to resign from any position? * Yes No If yes, provide reason * Educational Background List all educational schools attended with degrees, diplomas or certificates received. * Certification If you hold a current certification as a nurse aide (CNA). check the appropriate certification(s) below: * Long Term Care (L TC) Home Health Aide (HHA) Adult Day Care (ADC) Residential Care Aide (RCA) Developmental Disability Aide (DOA) Certified Medication Aide (CMA) 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-IA) 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 12-month certification period before your certification expires? Yes No If yes, where and when did you obtain. References List name, address and telephone number of three (3) references who are not relatives or former employers. * Background Information lf 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: l. 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. Have you ever: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pied 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 If yes, please explain. 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 If yes, please explain. 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? * Yes No If yes, please explain. 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? * Yes No If yes, please explain. Applicant's Certification and Agreement lf you answer 'No' to any of the questions below, explain in the space after the question. I understand the employer has the right to proceed with any criminal background check. * Yes No If no, please explain. I understand as a part of the job selection process, I may be required to take a drug-screening test al 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. * Yes No If no, please explain. 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. * Yes No If no, please explain. 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 * Yes No If no, please explain. I understand this form is not an employment contract. * Yes No If no, please explain. Previous CNA Training Complete this section only if you will require training. Please complete the followlng If you have had CNA Tralnlng In the past for any of these categories: LTC, HH, ADC, RC, or DDDC. Please include Category, Program Name, Start Date, End Date 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 l-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. 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. * By Checking this box I understand the above statement. Type Full Name * First Name Last Name I certify I have read and completed this application and that the information I have provided on this application is true and complete. Thank you!
