Application for Employment

Step 2

Preliminary Background Check and Registry Verification
Oakview Medical Care Facility is prohibited by both State and Federal Law from the employment of, independently contracting with, or granting clinical privileges to Ineligible Persons as defined and outlined in the attached OMCF Form 9-37 (Ineligible Persons) unless the specified number of years have lapsed from the end date of confinement and parole.
License / Certificate Information
(Number & State)
Conditional Employment Attestation.
I have been advised by Oakview Medical Care Facility that it may be necessary to conditionally employ, independently contract and / or grant clinical privileges to me prior to receiving all of the results of the state and national criminal history background information required by Michigan Public Act 28 of 2006 (An Act to amend Section 20173 of Public Act 368 of 1978, “The Public Health Care Act). Accordingly, I make the following representations while this information is being obtained and analyzed. I have reviewed the attached OMCF Form 9-37 (Ineligible Persons) and swear under penalty of law that:
  1. I have not been convicted of a felony or misdemeanor within the applicable time period that makes me ineligible, by law, to work for this organization.
  2. I am not the subject of an order or disposition under section 16b of Chapter IX of the criminal procedure, 1927 PA 175, MCL 769.16(b) relating to findings of not guilty by reason of insanity.
  3. I have not been the subject of a substantiated finding of neglect, abuse or misappropriation of property by a state or federal agency pursuant to an investigation arising in a skilled nursing facility and conducted in accordance with 42 USC 1395i-3 or 1396r.I agree that, if the information in the criminal history investigation conducted by this organization does not confirm my statements, my employment, contract or clinical privileges will be terminated unless and until I can prove that the information is incorrect. I further agree that if this results in a period of unemployment, suspension, or leave of absence, it will be without compensation and without fringe benefits.
Acknowledgement.
I understand that:
  1. The conditions set forth in Public Act 28 of 2006 that result in my termination and agree that these conditions are in fact good cause for termination.
  2. The provision of false information regarding my identity or criminal history is a crime punishable by imprisonment for not more than 93 days or a fine of not more than $500.00, or both.
  3. At some time during the job offer process, the signing of an independent contract, or the granting of clinical privileges, I will be required to submit a set of electronic fingerprints.
Consent
I have truthfully and accurately completed the information requested by Oakview Medical Care Facility on this form in order to enable the Facility to complete required Federal and State Criminal History Background Checks and License / Certificate Registry Verification. I consent to any and all checks required by the Facility pursuant to the requirements of State and Federal Law. I understand that these required checks will include checks with the U.S. Department of Health and Human Services Medicare / Medicaid Exclusion List; the Internet Criminal History / Access Tool (ICHAT); the Nurse Aide Registry (NAR); the Federal Offender Tracking Information System (OTIS); and the Public Sex Offender Registry (PSOR).


Pre-Employment Drug Screen Consent
Oakview Medical Care Facility is committed to providing an employment environment that is safe and provides appropriate motivation to ensure high quality resident care. To this end, the Facility unequivocally endorses the philosophy that the workplace be free from the detrimental effects of illicit drugs and alcohol. Please complete Part A. and submit it with your application for employment.

I, the undersigned job applicant, agree to submit urine and / or blood specimens at the place and time requested by Oakview Medical Care Facility for drug screen analysis in order to affirm my non-use of illegal drugs and / or controlled substances. I further authorize the results of this screen to be provided to Oakview’s Human Resource Manager or designee.

I understand that I may revoke this consent in writing, except as to the actions that Oakview Medical Care Facility has already taken action upon this consent.

I understand that I must satisfactorily pass a post job offer drug screen in order to secure employment at Oakview Medical Care Facility.

Finally, I further understand that I may refuse to sign this consent, but that by doing so my application for employment at Oakview Medical Care Facility will not be favorably considered.

(Type your name here to agree and authorize.)