MEADOW VIEW NURSING CENTER NURSING ASSISTANT TRAINING CLASS APPLICATION NAME: DATE: ADDRESS: PHONE: WORK SOCIAL SECURITY NUMBER Are You Currently Employed? YES NO Have you ever attended Nurse Assistant Training Class before? If so, where Do you have a High School Diploma or GED? YES NO In order to permit a check of your work and education records, please indicate any and all other names you have used in the past: Have you ever been convicted of a crime other than a summary offense? Yes No If yes, explain MEADOW VIEW NURSING CENTER IS A DRUG-FREE WORK PLACE! S: CNA Training Class/Nursing Assistant Training Class Application (revised 10-2010, 6-13-11, 2-12-12)
PHYSICAL REQUIREMENTS: Must be able to move intermittently throughout the work day. yes no Must be able to cope with the mental and emotional stress of the position. yes no Must be able to see and hear, or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met. yes no Must be in good general health and demonstrate emotional stability. yes no Must be able to speak the English language in an understandable manner yes no Must be able to perform the following: A. Lifting 0-50 lbs frequently 51 100 lbs occasionally 101-150 lbs rarely Over 151 lbs never B. Pushing 0 30 lbs frequently 31 90 lbs occasionally 91 200 lbs occasionally Over 200 lbs rarely C. Pulling/ Transfer 0-30 lbs occasionally 31 90 lbs occasionally 91 200 lbs rarely Over 200 lbs rarely D. Mobility Walking Frequently Standing Frequently Position Change Frequently Bending Frequently Stooping Frequently Sitting Occasionally Reaching Occasionally Climbing Rarely May be exposed to infectious waste, disease, conditions, etc. yes no Including exposure to the Aids and Hepatitis B Viruses. Signature Date
NURSING ASSISTANT TRAINING PROGRAM REFERENCE CONSENT FORM I, Hereby give Meadow View Nursing Center my consent to contact the following references: SUBMIT 2 WRITTEN REFERENCES (Do Not Include Relatives) PLEASE COMPLETE THE FOLLOWING INFORMATION: 1. NAME ADDRESS PHONE 2. NAME ADDRESS PHONE PREVIOUS EMPLOYERS: 1. COMPANY PHONE DATES OF EMPLOYMENT POSITION HELD 2. COMPANY PHONE DATES OF EMPLOYMENT POSITION HELD APPLICANT SIGNATURE DATE
MEADOW VIEW NURSING CENTER 1404 Hay Street Berlin, Pa 15530 814-267-4212 I am aware of the requirements of Acts 169 and 13 wherein all employees of a nursing facility must have a criminal background check. Please check one: I have been a resident of Pennsylvania for two (2) or more years immediately prior to this application for employment. I have NOT been a resident of Pennsylvania for two (2) years immediately prior to this application for employment. By my signature below, I affirm that I have NOT been convicted of any one of the offenses contained in Acts 169 and 13 as listed on the reverse side of this form. Signature of Applicant Date FOR OFFICE USE ONLY Attach a copy of a provisional applicant s proof that he/she has applied for a criminal background check.
Meadow View Nursing Center Applicant Attestation Statement In Accordance With Act 169 I the undersigned having been offered employment at Meadow View Nursing Center, a nursing facility, understand that as a condition of my hire, a criminal background check will be completed. I must complete the following sections and certify that my answers are truthful and correct I do hereby attest that I have been, have NOT been a resident of the State of Pennsylvania during the last 2 years prior to my application. I also understand that if I have NOT been a resident of the State of Pennsylvania during the two (2) years that a FBI check will be conducted. This will require that I be fingerprinted to conduct the FBI check. I further attest that I have NOT been convicted nor plead guilty of any of the attached list of charges. I understand that a conviction of guilty plea may prohibit my employment at Meadow View Nursing Center. Applicant s Full Name Print Maiden Name ( if applicable) Social Security Number Date of Birth Current Street Address City, State, and Zip Code Driver s License Number and State Date Applicant s Signature Federal and State Law Posters, posted on Level 2
OLDER ADULTS PROTECTIVE SERVICES ACT May-11 Prohibitive Offenses Contained in Act 169 of 1996 as Amended by Act 13 Following Offenses as Contained in PA Crimes Code (18 Pa.C.S.) Offense Code Prohibitive Offense Description Typing/Grade of Conviction CC2500 Criminal Homicide Any CC2502A Murder I Any CC2502B Murder II Any CC2502C Murder III Any CC2503 Voluntary Manslaughter Any CC2504 Involuntary Manslaughter Any CC2505 Causing or Aiding Suicide Any CC2506 Drug Delivery Resulting in Death Any CC2702 Aggravated Assault Any CC2901 Kidnapping Any CC2902 Unlaw ful Restraint Any CC3121 Rape Any CC3122.1 Statutory Sexual Assault Any CC3123 Involuntary Deviate Sexual Intercourse Any CC3124.1 Sexual Assault Any CC3125 Aggravated Indecent Assault Any CC3126 Indecent Assault Any CC3127 Indecent Exposure Any CC3301 Arson and Related Offenses Any CC3502 Burglary Any CC3701 Robbery Any CC3901 Theft CC3921 Theft By Unlaw ful Taking CC3922 Theft By Deception CC3923 Theft By Extortion Any CC3924 Theft By Property Lost ONE (1) FELONY CC3925 Receiving Stolen Property or CC3926 Theft of Services TWO (2) CC3927 Theft By Failure to Deposit MISDEMEANORS CC3928 Unauthorized Use of a Motor Vehicle Within the 3900 Series CC3929 Retail Theft (CC3901-CC3934) CC3929.1 Library Theft CC3929.2 Unlaw ful Possesion of Retail or Library Theft Instruments CC3929.3 Organized Retail Theft CC3930 Theft of Trade Secrets CC3931 Theft of Unpublished Dramas or Musicals CC3932 Theft of Leashed Properties CC3933 Unlaw ful Use of a Computer CC3934 Theft From a Motor Vehicle CC4101 Forgery Any CC4114 Securing Execution of Documents by Deception Any CC4302 Incest Any CC4303 Concealing Death of a Child Any CC4304 Endagering Welfare of a Child Any CC4305 Dealing in Infant Children Any CC4952 Intimidation of Witnesses or Victims Any CC4953 Retaliation Against Witness or Victim Any CC5902B Promoting Prostitution Felony CC5903C Obscene or Other Secual Materials to Minors Any CC5903D Obscene or Other Sexual Materials Any CC6301 Corruption of MInors Any CC6312 Sexual Abuse of Children Any Offenses as Contained in PA controlled Substance, Drug, Device & Cosmetic Act (P.L. 233 No 64) - PARTIAL LISTING* Offense Code Prohibitive Offense Descriptor Type/Grade of Conviction CS13A12 Acquistion of Controlled Substance by Fraud Felony CS13A14 Delivery by Practitioner Felony CS13A30 Possession w ith Intent to Deliver Felony CS13A35 (i), (ii), (iii) Illegal Sale of Non-Controlled Substance Felony CS13A36 Designer Drugs Felony CS13Axx* ANY OTHER FELONY DRUG CONVICTION APPEARING ON A PA RAP SHEET Produced by: PA Department of Aging May 1, 2011