Applicant Notice: You are applying for employment with the above listed Facility. To be eligible for employment,
you must read and agree to the following ‘conditions of employment;’ then sign below.
THIS IS A DRUG-FREE WORKPLACE
ANY PERSON EMPLOYED BY THIS FACILITY SHALL BE SUBJECT TO RANDOM DRUG OR ALCOHOL TESTING AT ANY TIME AND AT THE
FACILITY’S DISCRETION.
********************
POST- EMPLOYMENT PHYSICAL
THIS FACILITY REQUIRES ALL EMPLOYEES TO HAVE A MEDICAL EXAMINATION. AFTER AN EMPLOYMENT OFFER HAS BEEN MADE TO A
JOB APPLICANT AND BEFORE THE APPLICANT BEGINS THEIR EMPLOYMENT DUTIES, THEY MUST HAVE A MEDICAL EXAMINATION.
ALL OFFERS OF EMPLOYMENT ARE MADE CONTINGENT ON THE MEDICAL EXAMINATION RESULTS. THE SUCCESSFUL APPLICANT MUST
BE QUALIFIED AND MUST BE ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION THEY HAVE APPLIED FOR, WITH OR
WITHOUT REASONABLE ACCOMMODATIONS.
********************
CRIMINAL RECORD’S CHECK
TO BE ELIGIBLE FOR EMPLOYMENT WITH THIS FACILITY, EVERY EMPLOYEE WILL BE CHECKED AGAINST THE OIG EXCLUSION
CHECKLIST (PRE-EMPLOYMENT and PERIODICALLY POST-EMPLOYMENT). EVERY EMPLOYEE MUST SUBMIT TO A CRIMINAL RECORDS
CHECK WITHIN 5 DAYS OF EMPLOYMENT.
WHEN EMPLOYED, THE APPLICANT WILL BE CHARGED $22.00 FOR THE COST OF THE BCI&I (Ohio Bureau of Criminal
Identification and Investigation) CRIMINAL RECORDS’ CHECK. IF THE EMPLOYEE-APPLICANT HAS NOT BEEN A RESIDENT OF
OHIO FOR MORE THAN 5 YEARS, THEY WILL ALSO BE CHARGED $29.00 FOR THE COST OF THE FBI (Federal Bureau of
Investigation) CRIMINAL RECORDS CHECK.
THE COST OF THE RECORDS CHECK SHALL BE DEDUCTED FROM THE EMPLOYEE’S FIRST PAYCHECK, THROUGH A PAYROLL DEDUCTION.
BECAUSE THIS IS A ‘CONDITION OF EMPLOYMENT,’ AN APPLICANT WILL NOT BE CONSIDERED FOR EMPLOYMENT WITHOUT THEIR
AGREEMENT TO PAY FOR THE REQUIRED CRIMINAL RECORDS’ CHECK. (Your signature is required below.)
********************
I have read and understand the above listed requirements. I understand my employment with the Facility is “at
will” and is contingent upon the successful passage of my criminal background check, past employment references
and my post-employment medical examination.
With my signature, I certify that I currently not under investigation for or been convicted of a crime that may
exclude me from employment in a nursing facility. I also understand that a criminal records check is a condition
of employment and that I will be responsible for the cost of said records’ check. I HEREBY APPROVE the deduction
of the associated cost of said records check(s) from my paycheck.
Personal Information
If a liceication is required for the position in which you are applying (Examples: LPN, RN, STNA, LSW), are you
currently under investigation or have any active/pending suspensions/violations on your license to practice?
This includes any conviction(s) that occurred when you were a minor or records that have been sealed or
expunged.
ARE YOU CURRENTLY UNDER INVESTIGATION OR HAVE EVER BEEN CONVICTED OF RESIDENT ABUSE, A MEDICARE OR MEDICAID
OFFENSE OR BEEN EXCLUDED FROM PARTICIPATION IN A STATE OR FEDERAL HEALTH CARE PROGRAM THAT WOULD PRECLUDE YOU
FROM WORKING IN A NURSING FACILITY?
In accordance with 42 U.S. Code § 1320a-7 and ORC § 3721.121, you are notified that this Company is required to
complete an OIG Exclusion Check at the time of application and periodically after employment; and will search
your criminal background. Any “convictions of”, “pleading guilty to”, or “no contest pleas” to the attached
listed offenses, when required, will result in termination. If the criminal background check is not returned to
us within 30 days of your date of hire, you will be suspended and subject to be terminated.
Name/ Address of 3 persons, not related, whom you have known at least one year, include phone #.
List employment with your most recent or current position first. Account for any time during this period that
you were unemployed by stating the nature of your activities. Please indicate if you were employed under a
different name. We are required to complete employment reference checks.
Please Read Carefully. By signing below, I attest the information provided is truthful and complete.
In submitting this application for employment, I understand that an investigation may be made whereby
information is obtained regarding my character, previous employment, and/ or criminal history. I authorize
anyone possessing this information to furnish it to the Company listed on the front of this application and I
release anyone so authorized from all liability and damages whatsoever in furnishing, obtaining or using said
information. In the event of employment, I understand that false or misleading information given in my
application or during my interview may result in immediate dismissal. I understand, also, that I am required to
abide by all rules and regulations of this Company. I understand my employment is contingent upon the completion
of an OIG Exclusion Check, a Nurse Aide Registry Check and a successful criminal background check on or before
hire. I understand and agree that if employed, my employment will be “at-will”. That is, either I or the Company
may end the employment relationship at any time, for any reason. I understand that receipt of this application
does not imply employment and that this application and/ or any other Company documents are not contracts of
employment.
