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I, , certify by signature below that:
1. I have not been found guilty of abusing, neglecting or mistreating individuals by a court of law;
2. I am not the subject of a pending criminal charge of abusing, neglecting or mistreating individuals; or
3. I have no findings entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property.
I understand that the above listed statements are not limited to the abuse, neglect or mistreatment of a resident or patient, but applies to any individual to whom I was in a responsible or care taker position. Furthermore, as terms of employment I understand that it is my obligation to inform the facility of any pending charges, pleas or convictions involving myself or any other employee of the facility.
For the purpose of compliance with Federal Regulation Vol 56, No. 187; No. 483.13 (c) (1) (ii)(A); I authorize the Bureau of Criminal Apprehension to disclose all information that could relate to criminal charges of abusing, neglecting or mistreating individuals to Towner County Medical Center for the purpose of employment with this healthcare facility.
The expiration of this authorization shall be one year from the date of my signature.
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