Medication aide

INVESTIGATION FOR CRIMINAL CONVICTIONS

*. I understand that my employment is temporary until an investigation is made to see if I have a conviction for a felony or misdemeanor for certain types of offenses. A complete listing of the offenses is located in the facility policy for Criminal Background Checks.

2. I understand the Texas DPS Criminal records, Nurse Aide Registry, and Misconduct Registry will all be accessed for any record of violation that could bar employment from this facility. 3. I understand that I will be immediately terminated if I have a conviction for an offense like those listed in Chapter 250 of the Health and Safety Code or listed under the current facility policy. 4. I understand that I must provide the following listed information for purposes of the facility to assist in completing a background investigation.

5. The Misconduct Registry is a tracking system conducted by the DADS that maintains a listing of any individual that has committed the act of abuse, neglect, exploitation, or misappropriation. This facility will check this registry prior to hire and are prohibited from hiring anyone that is listed on the registry. 6. I have been informed that I may request a copy of the facility policy for criminal history checks. Below are some of the offenses that may bar employment. This listing is not all-inclusive of the offenses that may bar employment. For a full listing, please review the facility policy on Criminal Background Checks. Criminal Homicide, Kidnapping, Unlawful Restraint, Indecent Exposure, Indecency with a Child, Assault, Sexual Assault, Improper Relationship Between an Educator and Student, Injury to a Child, Elderly Individual or Disabled Individual, Deadly Conduct, Sale/Purchase of Child, Abandoning or Endangering Child, Agreement to Abduct from Custody, Terroristic Theat Online, Aiding Suicide, Arson, Robbery/Aggravated Robbery, Online Solicitation of a Minor, Money Laundering, Medicaid Fraud, Cruelty to Animals, Burglary, Theft, False Identification as a Policy Officer, Misapplication of Fiduciary Property or Property of a Financial Institution, Securing Execution of a Document by Deception, Disorderly Conduct Please Fill in the Information Below:

Name: Last, First, Middle: Other Names / Alias (Married, Maiden):

Social Security No.: Date of Birth:

Sex: (Male or Female) Race / Ethnicity: (Black, White or Other)

Facility Instructions: Use the above information to complete The Criminal HIstory Check Form. Place this copy in the Employee’s Personal File.