(APPLICANT, Sign and Date Both Sheets ONLY

(APPLICANT, sign and date both sheets ONLY. Leave remainder of forms blank. Fax to 580-237-6178)

Methodist Health Care Center / 301 South Oakwood Road / Enid, OK 73703

Phone: 580-237-6164 / Fax: 580-237-6178

REFERENCE RELEASE

Company ______Supervisor

Employee ______SS#

I hereby authorize my former employer to supply the information listed below. I release said company, officers, employees or individuals from any liability for any damages resulting from the disclosure of this information.

Employee’s Signature ______Date ______

The above named person has applied for a position with The Commons and has given your name as a reference. We are a nursing home providing care for the elderly. It is our aim to hire quality people and place them in positions where their talents and abilities are utilized as fully as possible. We would therefore appreciate your comments regarding character, habits, abilities and other attributes by filling in the information listed below. Information provided will be held in strictest confidence.

Dates of Employment: From ______To ______Position Held:

Please rate qualities by using the following scale:

4 = Excellent 3 = Good 2 = Fair 1 = Poor N/A = Not Applicable

_____ Quality of Work _____ Competence

_____ Knowledge of Skills _____ Attitude

_____ Reliability _____ Attendance

_____ Cooperation _____ Comprehension

_____ Supervisory Ability _____ Initiative

_____ Professional Appearance _____ Learns Quickly

Please indicate any special considerations necessary when giving assignments to this individual.

Is applicant eligible for rehire? Yes _____ No _____ If no, why not?

______

Signature and title of person giving reference Date

(APPLICANT, sign and date both sheets ONLY. Leave remainder of forms blank. Fax to 580-237-6178)

Methodist Health Care Center / 301 South Oakwood Road / Enid, OK 73703

Phone: 580-237-6164 / Fax: 580-237-6178

REFERENCE RELEASE

Company ______Supervisor

Employee ______SS#

I hereby authorize my former employer to supply the information listed below. I release said company, officers, employees or individuals from any liability for any damages resulting from the disclosure of this information.

Employee’s Signature ______Date ______

The above named person has applied for a position with The Commons and has given your name as a reference. We are a nursing home providing care for the elderly. It is our aim to hire quality people and place them in positions where their talents and abilities are utilized as fully as possible. We would therefore appreciate your comments regarding character, habits, abilities and other attributes by filling in the information listed below. Information provided will be held in strictest confidence.

Dates of Employment: From ______To ______Position Held:

Please rate qualities by using the following scale:

4 = Excellent 3 = Good 2 = Fair 1 = Poor N/A = Not Applicable

_____ Quality of Work _____ Competence

_____ Knowledge of Skills _____ Attitude

_____ Reliability _____ Attendance

_____ Cooperation _____ Comprehension

_____ Supervisory Ability _____ Initiative

_____ Professional Appearance _____ Learns Quickly

Please indicate any special considerations necessary when giving assignments to this individual.

Is applicant eligible for rehire? Yes _____ No _____ If no, why not?

______

Signature and title of person giving reference Date

OSBI Criminal Arrest Check

The Oklahoma Nursing Home Care Act requires that all nursing facilities run a criminal arrest check on all individuals applying for employment. The employer may make an offer of temporary employment, pending the results of the criminal arrest check. The employer may not hire an individual whose criminal background check includes a conviction of the following:

· Assault, battery, or assault with a dangerous weapon

· Aggravated assault and battery

· Murder or attempted murder

· Manslaughter, except involuntary manslaughter

· Rape, incest or sodomy

· Indecent exposure or indecent exhibition

· Pandering

· Child abuse

· Abuse, neglect or financial exploitation of any person entrusted to his care or possession

· Burglary in the first or second degree

· Robbery in the first or second degree

· Robbery or attempted robbery with a dangerous weapon or imitation firearm

· Arson in the first or second degree

· Unlawful possession or distribution, or intent to distribute unlawfully, Schedule I through V drugs as defined by

Uniform Controlled Dangerous Substance Act

· Grand larceny, petty larceny or shoplifting within the past seven years

An employer who receives a background check including one of these criminal convictions listed above must immediately terminate the individual’s employment if hired on a temporary basis.

Another provision of the act is that an employer may not employ or continue to employ a person addicted to any Schedule I through V drug specified by the Uniform Controlled Substances Act unless the person produces evidence that the person has successfully completed a drug rehabilitation program.