Alternative Community Services, Inc. of Greater Houston
- Office: 281-668-8820 | E-Fax: 844-371-1091
- 1035 Dairy Ashford Rd. Suite 142 Houston, TX 77079
- oscott@alternativecommunitysvs.net
Alternative Community Services, Inc. of Greater Houston
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act.
I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact orhave access to patient records until results are returned. I will be notified of results
• An offense under Chapter 19, Penal Code (criminal homicide);
• An offense under Chapter 20, Penal Code (kidnaping and unlawful restraint);
• An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or
children);
• An offense under Section 21.08, Penal Code (indecent exposure);
• An offense under Section 21.11, Penal Code (indecency with a child);
• An offense under Section 21.12, Penal Code (improper relationship between educator and
student);
• An offense under Section 21.15, Penal Code (improper photography or visual recording);
• An offense under Section 22.011, Penal Code (sexual assault);
• An offense under Section 22.02, Penal Code (aggravated assault);
• An offense under Section 22.021, Penal Code (aggravated sexual assault);
• An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabledindividual);
• An offense under Section 22.041, Penal Code (abandoning or endangering a child);
• An offense under Section 22.05, Penal Code (deadly conduct);
• An offense under Section 22.07, Penal Code (terroristic threat);
• An offense under Section 22.08, Penal Code (aiding suicide);
• An offense under Section 25.031, Penal Code (agreement to abduct from custody);
• An offense under Section 25.08, Penal Code (sale or purchase of a child);
• An offense under Section 28.02, Penal Code (arson);
• An offense under Section 29.02, Penal Code (robbery);
• An offense under Section 29.03, Penal Code (aggravated robbery);
• An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);
• An offense under Section 33.021, Penal Code (online solicitation of a minor);
• An offense under Section 34.02, Penal Code (money laundering);
• An offense under Section 35A.02, Penal Code (Medicaid fraud);
• An offense under Section 36.06, Penal Code (obstruction or retaliation);
• An offense under Section 42.09, Penal Code (cruelty to livestock animals);
•An offense under Section 42.092, Penal Code (cruelty to nonlivestock animals); or
• A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of anoffense listed by this subsection.
• An offense the Agency determines to be contraindicated to employment with the consumers theAgency serves
(B) A person may also be barred from employment the duties of which involve direct contact with a client in a facility if convicted of any of the following crimes within the past 5 years:
• An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or asa felony);
• An offense under Section 30.02 , Penal Code (burglary);
• An offense under Chapter 31, Penal Code (theft that is punishable as a felony);
• An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property ofa financial institution), that is punishable as a Class A misdemeanor or a felony; or
• An offense under Section 32.46, Penal Code (securing execution of a document by deceptionpunishable as a Class A misdemeanor or a felony) .
• An offense under Section 37.12, Penal Code (false identification as a peace officer); or
• An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).
(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not beemployed in a facility licensed under Chapter 242 or 247 if the person has been convicted:
• Of an offense under Section 30.02, Penal Code (burglary); or
• Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under
Section 30.02, Penal Code.
(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for anoffense 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 these offenses may also bar myemployment. I understand that all information obtained by this agency regarding any criminal history will remain
confidential.
I certify that the information on this form contains no willful misrepresentation and that the information given is trueand complete to the best of my knowledge.