§690.80. Application for Employment, Assignment, or Referral

Each licensee shall require an applicant to complete in writing an application form which contains, but is not limited to the following:

 

a)         Name and address of the applicant with verification of the applicant's identity by means of a valid driver's license, Secretary of State's identification card, passport or other appropriate identification which includes a photograph of the applicant;

 

b)         Written verification from the Department of Professional Regulation indicating the license and licensure status of a RN or LPN;

 

c)         Written verification from the Department of Public Health that a CNA has been registered as having completed a course which has been certified by that agency;

 

d)         Dates and places of the most recent previous employment references;

 

e)         A statement completed within the last twelve (12) months, that the applicant:

 

1)         has been administered the Mantoux tuberculosis test by a physician or a RN.  The date the test results were read shall be indicated in writing on the application form;

 

2)         has completed a CPR training course - date of certification shall be indicated in writing on the application form;

 

3)         has completed skill inventory and listed clinical areas of competence.