Race/Ethnicity (according to EEOC categories)
By execution of this document, I acknowledge that I have been informed by the agency that a criminal history, an EMR/NAR, and State and Federal OIG checks will be performed on my name(s). In addition, if I am hired, the agency will verify EMR/NAR annually, and OIG (State & Federal) monthly. I have informed this agency of all names (i.e., maiden name, aliases) that I have used in the past. I hereby profess that I have not been convicted of any of the following crimes which are a permanent automatic bars to employment by this agency.
A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed below:
- Chapter 19, Penal Code (criminal homicide)
- Chapter 20, Penal Code (kidnapping & unlawful restraint);
- Section 21.11, Penal Code (indecency with a child); or Section 21.02, Penal Code (continuous sexual abuse of young child or children)
- Section 22.011, Penal Code (sexual assault);
- Section 22.02, Penal Code (aggravated assault);
- Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
- Section 22.041, Penal Code (abandoning or endangering child);
- Section 22.08, Penal Code (aiding suicide);
- Section 25.031, Penal Code (agreement to abduct from custody);
- Section 25.08, Penal Code (sale or purchase of a child);
- Section 28.02; Penal Code (arson);
- Section 29.02, Penal Code (robbery);
- Section 29.03, Penal Code (aggravated robbery);
- Section 21.08, Penal Code (indecent exposure);
- Section 21.12, Penal Code (improper relationship between educator and student);
- Section 21.15, Penal Code (improper photograph or visual recording);
- Section 22.05, Penal Code (deadly conduct);
- Section 22.021. Penal Code (aggravated sexual assault);
- Section 22.07, Penal Code (terroristic threat);
- Section 32.53, Penal Code (exploitation of child, elderly individual, or disabled Individual);
- Section 33.021, Penal Code (online solicitation of a minor);
- Section 34.02, Penal code (money laundering);
- Section 35A.02, Penal Code (Medicaid fraud);
- Section 36.06, Penal Code (obstruction or retaliation);
- Section 42.09, Penal Code (cruelty to livestock animals); or Section 42.092, Penal Code (cruelty to non livestock animals);
A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is convicted of:
- Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
- Section 30.02, Penal Code (burglary);
- Chapter 31, Penal Code (theft), that is punishable as a felony;
- Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;
- Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
- Section 37.12, Penal Code (false identification as peace officer); or Section 42.01(a)(7), (8), or
- Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).
For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5 (c), Article 42.12, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.
I acknowledge that if I am found to have been convicted of any other offense(s), that this offense(s) may also bar my employment. Also, if I am found to have been reported to the Employee Misconduct Registry and/or OIG Excluded party Lists (State and/ or Federal), this offense(s) may also bar my employment.
I understand that all information obtained by this agency regarding any criminal history and employee misconduct will remain confidential. I have the right to contact DPS, DADS, and/or OIG to request an opportunity to be heard concerning the accuracy of the recorded information that was disclosed to the agency.
I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.