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Employment Application Supplement
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Med-Corp Plus, Inc. EMPLOYEE APPLICATION SUPPLEMENT A community services worker (CSW) may be prosecuted criminally for having sexual contact with a person in their care. CSWs must sign this form per 43A O.S. § 10-113 and 10 D.S. § 1430.3 known as the Breanna Bell Act. As I apply for a job as a CSW, I understand: • prior to hiring me, the community services provider is required by Oklahoma law to conduct a search of: criminal history records with Oklahoma State Bureau of investigation (OSBI); and • Oklahoma Department of Human Services (DHS) Community Services Worker Registry (Registry); • the community services provider is prohibited by Oklahoma law from hiring, contracting with, or using as a volunteer, any person: • convicted, plead guilty, or plead nolo contendere to misdemeanor assault and battery or a felony, except under circumstances described in Oklahoma Administrative Code (OAC) 340:100-3-39; or • whose name appears in the Registry; • my employment may be terminated if my name appears in the Registry, even though my name may not have been in the Registry at the time of my application or my hiring; - I must report to the community services provider all of my current and previous employers whc provide services to children and adults who are vulnerable; • giving false information regarding my current and previous employers may result in termination of my employment; and • Section 405.3 of Title 10 of the Oklahoma Statutes requires DHS to establish and maintain a Restricted Registry, also named Joshua's list. Individuals recorded on the Restricted Registry are prohibited from licensure, ownership, employment, unsupervised access to children, and/or residence in a facility or program, licensed, certified, operated, or contracted by, or with, DHS. Foster parents who contract with DHS are also subject to the Restricted Registry. Do you understand this?
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Provisional Employment
Med-Corp Plus, Inc. PROVISIONAL EMPLOYMENT I have not failed to comply with all federal, state and municipal laws as applicable to my professional license, certification, permit or employment class, as established by the authority having jurisdiction for my professional license, certification, permit, or employment class; (Place initials below to acknowledge this)
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I am not subject to an exclusion as described under Title 42 of the United States Code, Section 1320a-7; (Place initials below to acknowledge this)
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I am not currently the subject of a substantiated finding of neglect, abuse, verbal abuse, misappropriation of property, maltreatment, or exploitation, by any state or federal agency pursuant to an investigation conducted in accordance with Title 42 of the United State Code, Section 1935i-3(g)(1)(c) or 1396r(g)(1)(c), or Section 1-1950.7 or 1-1951 Title 63 of Oklahoma Statutes. (Place initials below to acknowledge this)
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I am not entered on the community services worker registry pursuant to Section 1025.3 of Title 56 of the Oklahoma Statutes. (Place initials below to acknowledge this)
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I am not recorded on the Child Care Restricted Registry pursuant to Section 405.3 of Title 10 of the Oklahoma Statutes. (Place initials below to acknowledge this)
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I am not registered pursuant to the Sex Offenders Registration Act, the Mary Rippy Violent Crime Offenders Registration Act, or registered on another state's sex offender registry; (Place initials below to acknowledge this)
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Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(L)(2), by my signature below I affirm and agree to the following:
a. I am not disqualified based on the disqualifying criteria listed above, b. I agree that, if the information in the registry screening and criminal history record check confirms that I am disqualified based on disqualifying criteria listed above, my employment, independent contract, or clinical privileges will be terminated unless and until I have appealed the determination and can provide that the information is incorrect, and c. I understand that false statements about disqualifying criteria will result in the termination of my employment, independent contract, or clinical privileges, and that those conditions are good cause for termination. Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(N), The period of provisional employment shall not exceed sixty (60) days pending the completion of the required background check. During this time the employee shall be subject to direct on-site supervision. The sixty-day time period may only be extended for those employees who are appealing the results of the background check. The time period shall only be extended for the duration of the appeal. Pursuant to Oklahoma law at Title 63 O.S. Section 1-1947(O), an individual who knowingly provides false information regarding his or her identity, criminal convictions, or substantiated findings on a statement described in subparagraph a of paragraph 2 of subsection L of this section is guilty of a misdemeanor punishable by a fine of not less than One Hundred Dollars ($100.00) nor more than Three Hundred Dollars ($300.00), imprisonment in the county jail for not more than thirty (30) days, or by both such fine and imprisonment. Do you understand this?
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