Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

Applicant Information:
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Match Criteria:
Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.
Education & Training:
Certifications and Credentials:
Please check all that apply, and enter the expiration date and any notes as applicable.
Active Type Expiration Date Notes
Car Insurance
Chest X-Ray
CNA License
Covid Vaccine
CPR Certification
Driver's License
First Aid Certification
Flu Vaccine
Hepatits B/Declination
HHA Certification
LVN/LPN Certification
Passport
Performance Evaluation
Registered Nurse
State ID Card
Tuberculosis Test

+ Add Additional Certification or Credential

Employment History:
Please provide your most recent positions of employment.

+ Add Additional Employer

Professional References:
Please provide professional references.

+ Add Additional Reference

Disclaimer:
I understand the OSDH will store the records of an employer's enrolled employees, the results of the screening and criminal arrest records search, and an identifier issued by the OSBI for the purposes of receiving and automatic notification from the OSBI if a subsequent criminal arrest record submitted into the system matches a set of fingerprints previously submitted. Upon notification, the OSBI will immediately notify the Department and the Department will immediately notify the employee. Information in the database established under this subsection is confidential, is not subject to disclosure under the Oklahoma Open Records Act, and shall not be disclosed to any person except for purposes of this act or for law enforcement purposes. The employee shall promptly respond to Department inquiries regarding the status of an arraignment or indictment. Reporting of an arraignment or indictment under this subsection may be caused for leave without pay, placement under direct supervision, restriction from direct patient access, termination, or denial of employment. [63 O.S § 1-1947(S)] Pursuant to 63 O.S. § 1-1947(I)(1), the employer shall submit the applicant's name, any aliases, address, former states in which the applicant resided, social security number, and date of birth. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application.
Signature:

To what day do you want to copy this shift?

Date:

Please choose an ID, date range and payer for the new authorization.

New ID:

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To*:

Paid By*:

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Right Now Scheduled Time

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