All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

List the last five years employment history, starting with the most recent employer.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

It requires that a health facility/agency that is a: psychiatric facility, hospital that provides swing bed services, ICF/MR, home for the aged, nursing home, home health agency, county medical care facility, or hospice — shall not employ, independently contract with, or grant clinical privileges to an individual who regularly has direct access to or provides direct services to patients or residents until a fingerprint-based criminal history check has been conducted.

NOTE: Throughout this form "employee" includes persons independently contracted with and/or those granted clinical privileges.

As a condition of being considered for employment:

a. I hereby consent to and authorize the health facility/agency to conduct a background check that includes a search of state and federal abuse and neglect registries and databases, in addition to a fingerprint-based search of state and federal criminal history records. I understand that this consent extends to the release and sharing of such information with the State Departments of Community Health, Human Services, Corrections, and State Police.

b. I hereby authorize the release of any relevant information to the health facility/agency to be used to conduct the background check as required under per state House Bill Rule.

c. I understand, except for a knowing or intentional release of false information, the health facility/agency has no liability in connection with a background check conducted under per state House Bill Rule, or the release of criminal history record information for the purposes of making an employment decision.

d. I understand that the health facility/agency will make the final employment determination. I also understand that the health facility/agency may terminate the background check or determine not to hire at any stage of the process.

e. I understand that the health facility/agency, in denying employment to an applicant, and reasonably relying on information obtained through a background check, is provided immunity from any action brought by an applicant due to the employment decision. I agree to provide the information necessary to conduct a criminal background check.

The following convictions and/or findings may disqualify you from working in a long-term care facility/agency: (a) Relevant Crime under 42 USC 1320a-7; (b) Any felony; (c) Certain misdemeanors including use of a firearm, assault, criminal sexual conduct, abuse or neglect, home invasion, embezzlement/fraud/theft, negligent homicide, or controlled substance offenses; (d) Not Guilty by Reason of Insanity; (e) Substantiated finding of patient or resident neglect, abuse, or misappropriation of property.

Listed below are all offenses that I have been convicted of, including all terms and conditions of sentencing, parole and probation, and/or any substantiated finding of patient or resident neglect, abuse, or misappropriation of property.

I certify that the above statements are correct and complete to the best of my knowledge.

If the health facility/agency determines it necessary to employ me pending the results of the state and federal criminal history background check, I understand the following:

a. If the background check does not confirm my disclosure statement, my employment will be terminated for good cause, unless and until I successfully prove the disqualifying information is inaccurate, expunged, or set aside.

b. If I knowingly provided false information regarding my identity, criminal convictions, or substantiated findings of neglect, abuse, or misappropriation of property, I may be guilty of a misdemeanor punishable by imprisonment for not more than 93 days and/or a fine of not more than $500.00.

c. As required by MCL 333.20173a and MCL 330.1134a, I agree that as a condition of continued employment, I shall report in writing to the health facility/agency immediately upon being arraigned on a felony charge or convicted of one or more criminal offenses described therein, or upon becoming the subject of an order of "Not Guilty by Reason of Insanity", or upon being the subject of a substantiated finding of patient or resident neglect, abuse, or misappropriation of property. Reporting of an arraignment is not cause for termination or denial of employment.

I understand that upon my request, the health facility/agency can provide a copy of any disqualifying record information found on any of the relevant registries or databases.

I understand that if I believe the results of any disqualifying information found on any relevant registry is inaccurate, it is my responsibility to contact the agency that maintains the registry to correct the registry information.

I understand that if I believe the results of the criminal history fingerprint record are inaccurate, or if the conviction contained in the criminal history record is one that may be expunged or set aside, I may file an appeal with the Department of Community Health.