EMPLOYMENT FORM

PERSONAL INFORMATION







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YesNo

EDUCATIONAL HISTORY

Type of School Name & Location of School Year Attended Graduate Degree
High School
College
College
College

EMPLOYMENT AVAILABILITY

Hrs Available Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM

PM

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YesNo

EMPLOYMENT AVAILABILITY




EMPLOYMENT HISTORY




EMPLOYMENT HISTORY




PROFESSIONAL REFERENCES

APPLICANT CERTIFICATION AND ACKNOWLEDGEMENTS

REFERENCE CHECKS

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for positions without regard to race, color, religion, sex, national origin, age, disability or veteran status.

STATEMENT OF EMPLOYABILITY






MaleFemale

Terms & Conditions




Criminal History Check


I have informed this agency of all names (i.e. maiden, aliases) that I have used in the past. I understand that my employmentis pending the results of the criminal history check, and that I may not have face-to-face contact until results are returned.

CONVICTIONS BARRING EMPLOYMENT

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


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

• An offense under Chapter 20, Penal Code (kidnapping and false imprisonment);

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

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

• An offense under Section 21.11, Penal Code (indecency with a child);

• 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 22.011, Penal Code (sexual assault);

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

• An offense under Section 22.021, Penal Code (aggravated sexual 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 22.05, Penal Code (deadly conduct);

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

• 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 33.021, Penal Code (online solicitation of a minor);

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

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

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

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

• Any offense HNTS determines to be contraindicated to employment with the consumers the Agency serves.

• 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.

X.: Forms\ Statement of Employability 20 1 1.doc

(13) 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 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 a punishable as a felony);

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

• An offense under section 37.12, Penal Code (false identification as a peace officer }; or

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



(C) In addition to the prohibitions on employment prescribed 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. (D) In addition to the
prohibitions on employment prescribed by Subsections (A), (B), and (C), a nurse aide listed as unemployable per amendment
to TAC 40, §94.10(1) and §94.11(c) (d) and is listed on the NAR or EMR stating a finding of neglect or abuse, neglect, or misappropriation will not be recertified therefore, is unemployable.



(E) 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 Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offense(s) may also bar my employment.I understand that all information obtained by Home Nursing & Therapy Services 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 Check completed on-lineEMR checked online at http://www.dads.state.tx.usiproviders/employability/esearch.cfmNARApplicant EmployableApplicant not Employable


The importance of checking references on personnel working in a life/death situation cannot be overemphasized. The applicant whose signature appears below has given your name as a source of reference. May we count on your assistance in substantiating the qualifications of our applicant?

You can count on our strict confidence in handling any information you may want to let us have. For your convenience, you may return this by fax at (210)822-8863.

Thank you in advance for your courtesy and cooperation.

Sincerely,

Personnel Manager




SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE
Quality of work
College
Reliability & punctuality
Adaptability to situations
Health
Attendance
Quantity of work
Initiative
Overall Nursing Skills


YesNo

The importance of checking references on personnel working in a life/death situation cannot be overemphasized. The applicant whose signature appears below has given your name as a source of reference. May we count on your assistance in substantiating the qualifications of our applicant?

You can count on our strict confidence in handling any information you may want to let us have. For your convenience, you may return this by fax at (210)822-8863.

Thank you in advance for your courtesy and cooperation.

Sincerely,

Personnel Manager




SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE
Quality of work
College
Reliability & punctuality
Adaptability to situations
Health
Attendance
Quantity of work
Initiative
Overall Nursing Skills


YesNo


I hereby declare that the above information is true to the best of my knowledge and I shall be solely responsible for any false information furnished by me.