EMPLOYEE MISCONDUCT REGISTRY/CRIMINAL HISTORY

CERTIFICATION VERIFICATION/O.I.G.

Applicant Form:

Print Name: Certificate or License Number (if applicable):
Social Security Number: Date of Birth*
Gender:*
The State of Texas prohibits the hiring of an individual who is listed in the Employee Misconduct Registry and the Nurse Aide Registry as having abused, neglected, exploited a resident of a facility or misappropriated a resident’s property.
Before you are hired, your name will be checked against the State of Texas Misconduct Registry, Nurse Aide Registry and the Office of Inspector General. If you are listed on any of these registries, you may be ineligible for employment.
By signing this, you are authorizing the company to run your criminal history report and thereafter your criminal history report will be re-run annually.

Employer to complete

NOTE - All registries and criminal history must be checked. (1-800-452-3934 – both registries)

Employee Misconduct Registry (Please choose one and put a checkmark):

___ Employee is not listed on the Employee Misconduct Registry.
___ Employee is listed on the Employee Misconduct Registry as unemployable.

Nurse Aide / Certified Med Aide Registry (Please choose one and put a checkmark):

___ Employee is not listed on the Nurse Aide Registry but is employable. (Complete nurse aide certificate information below)
Nurse Aide’s-Certified Med Aide certificate number is ______________. It expires ______________ Status _______________
___ Employee is listed on the Nurse Aide Registry as unemployable.

Certification / License Verification:

___ LVN certificate number is ______________ Expiration Date ___________ (LVN 1-512-305-8100)
___ RN certificate number is _______________Expiration Date ____________ (RN 1-512-305-7400)

Criminal History (mark one) (run through D.P.S)

___ Employee is eligible for employment
___ Employee is not eligible for employment

O.I.G. Exclusion List (mark one) (run through O.I.G. web site http://oig.hhs.gov)

___ Employee is not found on the exclusion list and is eligible for employment
___ Employee is found on the exclusion and is not eligible for employment

Checked by __________________________________________ Date ________________

Please enter your email for a copy of this form.

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