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Uniform Employment Application for Nurse Aide Staff

Effective November 1, 2012 the following Uniform Employment Application for Nurse Aide Staff will be in effect, ODH Form 805 (PDF). The revised form reflects changes to the list of offenses that are barriers to employment. See Revised Barrier Offense for Nurse Aides Effective November 1, 2012 (PDF).

As mandated by Title 63 of the Oklahoma Statutes (O.S.) Section 1-1950.4, the OSDH Nurse Aid Registry in conjunction with the DHS Office of the Ombudsman developed a Uniform Employment Application for Nurse Aide Staff. Statutory requirements mandate this form be used by facilities that employ nurse aides. These facilities include nursing facilities, specialized nursing facilities, residential care homes, continuum of care facilities, adult day care centers, assisted living centers, hospice agencies and programs, and home care agencies.

Title 63 O.S. Section 1-1950.4a became effective May 29, 2003. This section informs the applicant it is unlawful " provide false information regarding a criminal conviction on the uniform employment application..." Violation "...shall constitute a misdemeanor." If convicted, applicant shall be punished by fine and/or imprisonment.

The Uniform Employment Application is available below, along with copies of Title 63 O.S. Sections 1-1950.4 and 1-1950.4a, and rule, OAC 310:2-15,  that went into effect June 25, 2007.

Law and Rules

    Law Excerpt - Uniform Employment Application, 63 O.S. Section 1-1950.4

    Rule Excerpt - Uniform Employment Application, 310:2-15. Application Forms


    Uniform Employment Application for Nurse Aide Staff, ODH Form 805
        Do not submit this application to the Nurse Aide Registry.

Contact Information

Mailing Address:
Oklahoma State Department of Health
Nurse Aide Registry
PO Box 268816
Oklahoma City, OK 73126-8816

Physical Address:
Oklahoma State Department of Health
123 Robert S. Kerr Ave.
Oklahoma City, OK

Phone: 405-426-8150
Fax: 405-900-7572

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