Dear Prospective Student!
Thank you for your interest in the Education Program for Nurse Aide. Included in the application packet are:
Nurse Application for Admission, Barrier Crime and Criminal Background documents, Consumer Disclosure and
Authorization form, Financial Information with Admission requirements, Nurse Aide checklists, and photo release form.
Please return the completed application to:
Eddie or Tara Archer RN Nurse Aide Coordinator:
Healthcare Training
“We don’t make your career… we make it better!”
300 Enterprise Drive Suite B, Forest, VA 24551
Web: www.RaspberryHilladc.com Email: [email protected]
Facebook: www.facebook.com/raspberryhill.adultdaycenter
*Bring in person Monday-Friday 9:00am-1:30pm located at 300 Enterprise Drive Suite B, Forest VA
24551
(Drop box will be onsite for anytime drop off).
Read the Barrier Crimes List and the Sworn Disclosure Statement. Signing of the Raspberry Hill ADC Nurse
Aide Education Program application acknowledges your understanding of the restrictions placed on individuals
who can work as a Certified Nurse’s Aide based on the Barrier Crimes and the use of the Sworn Disclosure
Statement by certain facilities for employment screening purposes. Also please sign the consumer disclosure
authorization form this gives us permission to do an electronic background check.
o Payment is DUE for all classes upon registration. You will receive a letter of
acceptance into these programs and an invoice will be sent out for balance DUE.
This amount must be received by DUE date or your spot will be filled by another
candidate.
Please see the Administrator of the program for further assistance. It is imperative that the application be filled
out completely including three names and the contact information for your references. The agency will notify
the references. If you are receiving financial aid through Region 2000 Workforce Center or Goodwill for
tuition please let us know.
.
Incomplete applications will not be considered Follow the checklist at the end of the application to ensure it is
completed properly before sending it.
We look forward to meeting you!
CLASS INFORMATION:
www.Raspberryhilladc.com
*If you are unable to download and print the application packet please CALL our office or
email us your address and we will send you the packet via mail/email.
Nurse Assistant/ Training Program:
Raspberry Hill ADC Nurse Assistant meet’s all the requirements by the Virginia Board of Nursing
requirements for Nursing Assistant Training in Virginia. Our expectation is to set a high standard in
providing a quality program which in turn will promote high quality Nursing Assistant’s and in this field.
Your instructors are highly experienced Registered Nurses with a wide variety of experience in
healthcare. We are committed to your success and desire to see each of do well with proper
support in your journey.
The Nurse Aide course is a 120-hour long including 40 hours of clinical experience. Through
lecture, video, role-playing, and hands-on laboratory and clinical practice, you will learn procedural
skills such as bathing, dressing, positioning, and vital signs. Also you will learn key communication
techniques to provide compassionate care for people in the healthcare arena. Our classroom/lab is
equipped with a hospital bed, medical mannequin and all the necessary medical equipment to
practice skills. After graduation, you are eligible to sit for the Virginia Certified Nurse Aide
(C.N.A.) exam.
Admission Requirements
1.
2.
3.
4.
5.
6.
US citizenship or current Permanent Residence (Green) Card, Student(VISA), Working(VISA)
Copy of Current I.D. or Driver’s License, *VISA-Legal documentation
Must be able to read and write, and physically able to perform tasks.
Immunization Records, TB test. (See Nurse Aide Application for requirements.)
Criminal Background Check.
Flu vaccine (In season) October thru April only.
Note: The classroom, lab, and clinical sessions require the ability to learn in a fast-paced academic
environment coupled with physical activity. If you have any conditions that could affect your ability to
participate including learning disability, pregnancy, chronic conditions or an injury, please attach
written permission from your physician with this application. Applicable conditions revealed after
enrollment without permission to participate will be grounds for non-refundable dismissal.
*Class, Skills, Clinical
(See schedule)
*CLASSROOM/SKILLS LAB LOCATION:
*CLINICAL:
300 Enterprise Drive, Suite B Forest, VA 24551
*Westminster Canterbury 501 Ves Road
*AVANTE’ at Lynchburg 2081 Langhorne Road
Lynchburg VA 24501
Office 434-525-4422
Email: [email protected]
Notes: If accepted into the program you will be required to read our Handbook of policies for this program and
agree by signing a signature page.
Backgrounds checks/Barrier crimes are checked on all eligible candidates. Virginia Law will not allow persons
with certain felony or misdemeanor charges and/or convictions, called Barrier Crimes to participate in a skilled
nursing facility. You must pass this check. A list is included in the application.
*Attendance policy- Because of the pace and focus of this course, your expected to attend every clinical and
classroom instruction and to be on time. In case of emergency or illness that requires time to be missed, discuss
your situation with the instructor. A leave of absence and/or re-enrollment request may be submitted for
consideration.
*Admittance to this program is based on application review, references check, negative barrier crimes,
negative background check, and overall demonstration that you will be a successful candidate.
Once application is received with application/background check fee it will be processed within a week. If you
are accepted into the program you will be notified within that time frame.
Healthcare Training
“We don’t make your career… we make it better!”
300 Enterprise Drive Suite B, Forest, VA 24551
Web: www.RaspberryHilladc.com Email: [email protected]
Facebook: www.facebook.com/raspberryhill.adultdaycenter
It is the policy of the Raspberry Hill ADC Nurse Aide Education Program, in compliance with applicable federal, state and
local laws, not to discriminate against any applicant or to tolerate harassment because of race, color, religion, age, sex,
national origin or ancestry, genetic make-‐up, marital status, veteran’s status, physical or mental handicap unrelated in
nature and extent to an individual’s ability to fulfill the requirements of the program, or any other prohibited factor.
Please complete each section on this form and sign.
After completion, return to:
Tara Archer RN, Nurse Aide Coordinator
Raspberry Hill HealthCare Training
300 Enterprise Drive Suite B, Forest VA 24551
Print or Type All Information Below:
Date: _______________
Social Security Number: ______-‐______-‐_________ (Needed for background check)
Full Name: _________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
(Maiden Name)
Age: ________
Valid Driver’s License or I.D (copy):
Yes or No
Home Address: _________________________________________________________________________
Street Name
City
State
Zip Code
Telephone Number: Home: ______________________________ Cell: _____________________________
Are you currently authorized to attend an education program such as the Raspberry Hill ADC Education
Program in the United States? ☐Yes ☐ No
Person to Be Notified In Case Of Emergency:
Name:______________________________________________Relationship:________________________
Address________________________________________________________________________________
Street Name
City
State
Zip Code
Telephone Number Home/Cell: _____________________________________________________________
Have you graduated High School? If so, what year? _____________________________________________
*Are currently in school or home-schooled?
Yes or No
*If so, what grade are you in? ______________________________________________________________
Email address:__________________________________________________________________________
Regulations 18VAC90-‐25-‐20-‐B-‐3 state that each student applying to or enrolled in any Nurse Aide
education program shall be given a copy of applicable Virginia law regarding criminal history records checks
for employment in certain health care facilities, and a list of crimes which pose a barrier to such employment.
*A sworn disclosure statement regarding Section 32.1-‐126.01 of the code of Virginia and a list of Barrier
Crimes is included with this application. *Any person who has been convicted of a felony or misdemeanor
may not be eligible for licensure as a certified nurse aide or a medication aide in VA.
Any person who uses alcohol or drugs excessively may also be ineligible for licensure. (Section 54.1-‐3007
Code of Virginia)
Have you been convicted of a felony and/or misdemeanor since the age of 18? ☐ Yes ☐No
If yes, please give details [offense(s), date(s), sentence(s), etc.]
__________________________________________________________________________________________________
____________________________________________________________________________________________
Please list 3 professional references not relatives that can verify your character. (Agency will call.)
1. Name: _______________________________________________________________________________
Position or Title: ______________________________________
Address: _______________________________________________________________________________
2. Name: _______________________________________________________________________________
Position or Title: ______________________________________
Address:________________________________________________________________________________
3. Name: _______________________________________________________________________________
Position or Title: ______________________________________
Address:________________________________________________________________________________
Only applicant files that are complete will be reviewed or considered for admission. It is the applicant’s
responsibility to ensure that all required documentation is received by the Nurse Aide Education Program
Coordinator.
* It is my understanding that I will not be considered for admission to the Raspberry Hill ADC Nurse Aide
Education Program until I have submitted all documents as specified by the Program. I further agree to inform
the program coordinator of any changes in my plans to attend the Raspberry Hill ADC Nurse Aide Education
Program, address and/or legal name. I understand that withholding information requested in the application
or giving false information on any documentation may make me ineligible for admission to/or continuation in
the Raspberry Hill ADC Nurse Aide Education Program. I understand that by signing this application I
acknowledge receipt of and an understanding of the Barrier Crimes List and Student Catalog and Handbook.
If accepted for admission, I will authorize the Raspberry Hill ADC Nurse Aide Education Program to conduct
a criminal background investigation. The Program will be released from any and all claims arising out of such
investigation and testing. I understand that any false statements or omissions in response to the questions
relating to convictions may result in refusal to admit me to the Raspberry Hill ADC Nurse Aide Education
Program. I understand that any background check will comply with the Fair Credit Reporting Act. I further
understand that an applicant who meets all requirements is not guaranteed admission into the program. I
understand and agree that this is not an application for employment with Raspberry Hill ADC . I further
understand and agree that Raspberry Hill ADC does not guarantee me a job if I complete this Program and that
I will not be paid for attending the Program.
Please attach a summary of: Why you are interested in the Certified Nursing Assistant program and your
aspirations for the future. Please type or print:
Or use space below:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________________________________
Due before Orientation Day :
Tuition
☐Full Tuition $795.00 (APPLY EARLY FOR FINANCIAL AID). Workforce Center 434-455-5940 ext. 161
Cash, Personal or Cashier’s Check, Debit/Credit Card through PayPal, Financing option through PayPal Credit,
Money order (payable to: Raspberry Hill Adult Daytime Center)
Pay online: www.Raspberryhilladc.com “Make a payment” tab
Other Fees:
☐$10.00 Application/processing fee (DUE with application) (non-refundable)
☐$30.00 Background check (Due with application) (non-refundable) see details below.
☐Total DUE: Mailed in with Application Packet: $40.00 (non-refundable)
I understand that by signing this application I acknowledge receipt of and an understanding of the Barrier
Crimes List and Student Catalog and Handbook. I will authorize the Raspberry Hill Adult Daytime Center
Nurse Aide Education Program to conduct a Criminal background investigation and sexual offender registry
before acceptance into the program. I also attest that I have read the entire application and agree to it’s
terms including the tuition refund policy.
☐ I am sending the $10.00 fee to cover the Application fee.
☐ I am sending $30.00 fee for the Background check.
☐ I am sending Application and appropriate signed forms contained in this document.
Signature: ______________________________________________ Date: __________________________
To ensure the application is complete, check each item when completed and enclosed with application.
☐Fill out Application completely.
☐Read & sign List of Barrier Crimes and Sworn Disclosure Statement.
☐Fill out Consumer Disclosure and Authorization Form.
☐Read Prospective Raspberry Student Form & Financial Information.
☐Include Check, Cashier’s check or Money order made out to Raspberry Hill Adult Daytime Center for $10.00
application/processing fee & $30.00 Background check fee (total of $40.00).
*Also you can pay on our website under make a payment tab visa/credit/debit.
www.Raspberryhilladc.com
☐Give three (3) Reference names.
☐Age_____ Must be at least 17 years of age.
☐Copy of Valid Driver’s License or I.D. Card. (Copies of License or I.D. needed for ID verification).
☐Attach (if needed) your summary of your reasons and aspirations for taking the class.
☐Sign and date the application.
☐Signed Photo Release form.
This application will be considered incomplete if you have not placed your check beside each item above!
Incomplete applications will NOT be considered for admission into the program.
Thank you for your interest in the program! We are excited about partnering with you and helping you start
your new career in the medical field! *Our Nurse Aide program is competive. Your acceptance into the
program is based on your application, 3 references and a background check that has no barrier crimes listed.
*If you have been accepted into the program you will be notified within 1 weeks via email or phone.
Once accepted into the program your payment is due on Orientation day before the 1st day of class. If
no payment is received by the Orientation Day you will not be able to attend the class. You will be
referred to the Administrator for further assistance.
*Students are required to have the following vaccines or titers: Documentation will be required once
accepted into the program and will be required on Orientation Day.1.Hepatitis B vaccine or proof
2.Documented proof of 2 MMR vaccines or titer 3.Varicella vaccine documented proof of protection (positive
titer or two dates for the Varivax vaccine) 4. (PPD) Tuberculin Skin Test-within 30 days of attendance. *Med
Express, Personal Doctor’s Office, health department.
Background Checks
$30.00 Background Check is due with application.
$10.00 Application fee (due with application)
*Please apply for financial assistance early! Please read Financial Information sheet.
DO NOT wait until Orientation day to find out how to pay for the class. If you apply early to the resources we
gave you, your tuition might be paid in full or financed in FULL!
Thank you for your interest!
Joint statement of the Department of Health and the Department of Health Professions on
Impact of Criminal Convictions on Nursing Licensure or Certification and Employment in
Virginia
INTRODUCTION
Certain criminal convictions may prevent licensure as a nurse or certification as a nurse aide in Virginia. Criminal
convictions may also prohibit employment in certain health care settings.
This document provides information for persons interested in becoming a Certified Nurse Aide (C.N.A.), Licensed
Practical Nurse (L.P.N.), or Registered Nurse (R.N.). It clarifies how convictions and other past history may affect the
application process and subsequent licensure or certification by the Board of Nursing. It also clarifies the criminal
convictions that prohibit employment in nursing home facilities, home care organizations, hospice programs, and
assisted living facilities,1and identifies what is commonly referred to as “barrier crimes.”
Table of Contents
I. Impact of Convictions on Board of Nursing Licensure or Certification………………………………………………………………2
Application Process for Initial Licensure or Certification with the Board of Nursing…………………………………………….2
Basis for Denial of Licensure and Certification…..………………………………………………….3
Additional Information Needed Regarding Criminal Convictions,Past Actions, Or Possible Impairments……. 4
Following Licensure or Certification……………………………………………………………………………………………………………..5
II. Criminal Convictions and Employment………………………………………………………………………………………………………….6
Convictions that Do Not Disqualify an Applicant from Employment……………………………………………………………6
Disclosure of Criminal Convictions……………………………………………………………………………………………………………….7
III. Getting a Criminal Record Expunged…………………………………………………………………………………………………………….7
Appendix: Barrier Crimes Prohibiting Employment in Nursing Facilities,
Home Care Organizations and Hospice Programs……………………………………………………………………………………………..9
1
Individuals licensed or certified by the Board of Nursing may be eligible for employment in other health care settings, depending
upon the hiring and employment practices of the particular employer.
I. IMPACT OF CRIMINAL CONVICTIONS ON BOARD OF NURSING
LICENSURE AND CERTIFICATION
Criminal convictions can affect an individual during the licensure or certification
application process and may affect an individual’s employment options after licensure or
certification by the Board.
Until an individual applies for licensure or certification, the Board of Nursing is unable to review, or consider for approval,
an individual with a criminal conviction, history of action taken in another jurisdiction, or history of possible impairment.
The Board has no jurisdiction until an application has been filed.
APPLICATION PROCESS FOR LICENSURE OR CERTIFICATION
WITH THE BOARD OF NURSING
After successfully completing an approved nursing or nurse aide education program, the individual is eligible to apply for
licensure or certification by the Virginia Board of Nursing of the Department of Health Professions (DHP).
Effective January 1, 2016, there is requirement for RN and LPN initial applicants for licensure (by examination and
endorsement), as well as RN and LPN applicants for reinstatement, to submit to fingerprint-based state and federal
criminal background history checks (hereinafter “CBC”), pursuant to § 54.1-3005.1 of the Code of Virginia. See the
Board of Nursing website for more information, instructions, and Frequently Asked Questions (FAQs) regarding the CBC
process and its impact on the application process at: www.dhp.virginia.gov/nursing.
Applicants seeking licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) by examination: An application
for licensure by examination is made directly to the Virginia Board of Nursing. These applicants must also submit to a
CBC. Upon receipt of a completed application with appropriate application fee and an official transcript from the
nursing education program, as well as review of results from the CBC, the Board determines and communicates
eligibility for testing to the testing company that administers the NCLEX examination for licensure. The applicant must
also submit a separate registration form and fee to the testing company that administers the exam for licensure. Both
application for “licensure by exam” and the registration packet for the testing company are available from the Board of
Nursing web site or by calling the Board office at (804) 367-4515.The applications, registration and information about
testing may be obtained from the DHP - Board of Nursing website at: www.dhp.virginia.gov/nursing and choosing
“Forms and Applications.”
Applicants seeking certification as a Nurse Aide (CNA) by examination: The application for certification is made directly
to Virginia’s nurse aide testing service. Upon receipt of a completed application and appropriate fee, the testing service
verifies eligibility and administers the National Nurse Aide Assessment Program (NNAAP) exam for certification by the
Virginia Board of Nursing. The application for “certification by exam” and candidate handbook may be accessed directly
from the DHP - Board of Nursing website at www.dhp.virginia.gov/nursing, and choosing NNAAP. They may also be
obtained by calling the Board of Nursing-Nurse Aide Registry office at (804) 367-4569.
Applicants seeking licensure or certification by endorsement from another state: Endorsement applicants already
licensed or certified in other jurisdictions must apply directly to the Virginia Board of Nursing, unless applicants reside
and are licensed as a R.N. or L.P.N. in another state that is a member of the Nurse Licensure Compact.2 These applicants
must also submit to a CBC. Applications with instructions can also be accessed from the DHP- Board of Nursing web site
at www.dhp.virginia.gov/nursing and choosing “Forms and Applications.”
BASIS FOR DENIAL OF LICENSURE OR CERTIFICATION
According to § 54.1-3007 of the Code of Virginia, the Board of Nursing may refuse to admit a candidate to any
examination, or refuse to issue a license or certificate, to any applicant with certain criminal convictions. Likewise, the
Board may refuse licensure or certification to an applicant who uses alcohol or drugs to the extent that it renders the
applicant unsafe to practice, or who has a mental or physical illness rendering the applicant unsafe to practice (referred
to as a history of impairment).
Criminal convictions for ANY felony can cause an applicant to be denied nursing licensure or nurse aide certification.
Misdemeanor convictions involving moral turpitude may also prevent licensure or certification. Moral turpitude means
convictions related to lying, cheating or stealing. Examples include, but are not limited to: reporting false information
to the police, shoplifting or concealment of merchandise, petit larceny, welfare fraud, embezzlement, and writing
worthless checks. While information must be gathered regarding all convictions, misdemeanor convictions other than
those involving moral turpitude will not prevent an applicant from becoming a licensed nurse or C.N.A. However, if the
misdemeanor conviction information also suggests a possible impairment issue, such as DUI and illegal drug possession
convictions, then there still may be a basis for denial during the licensure or certification application process.
Each applicant is considered on an individual basis. There are NO criminal convictions or impairments that are an
absolute bar to nursing licensure or nurse aide certification.
ADDITIONAL INFORMATION NEEDED REGARDING CRIMINAL CONVICTIONS, PAST ACTIONS, OR POSSIBLE
IMPAIRMENTS
2
See § 54.1-3030 et.al. of the Code of Virginia for laws related to the Nurse Licensure Compact., which Virginia began participating
in on January 1, 2005. The Compact allows nurses licensed and residing in another Compact state to practice nursing in Virginia on a
multi-state privilege to practice without obtaining additional licensure here. However, if the applicant is moving to Virginia and
declares Virginia as the primary state of residency, licensure must be obtained here and the prior Compact state license will be
invalidated. For a current list of states in the Compact, go to http://www.ncsbn.org/nlc/rnlpvncompact_mutual_recognition_state.asp .
Applications for licensure and certification include questions about the applicant’s history, specifically:
1. Any and all criminal convictions ever received;
2. Any past action taken against the applicant in another state or jurisdiction, including denial of licensure or
certification in another state or jurisdiction; and
3. Any mental or physical illness, or chemical dependency condition that could interfere with the applicant’s
ability to practice.
Indicating “yes” to any questions about convictions, past actions, or possible impairment does not
mean the application will be denied. It means more information must be gathered and considered before a
decision can be made, which delays the usual application and testing process. Sometimes an administrative proceeding
is required before a decision regarding the application can be made. The Board of Nursing has the ultimate authority to
approve an applicant for testing and subsequent licensure or certification, or to deny approval.
The following information will be requested from an applicant with a criminal conviction:




A certified copy of all conviction orders (obtained from the courthouse of record);
Evidence that all court ordered requirements were met (i.e., letter from the probation officer if on supervised
probation, paid fines and restitution, etc.);
A letter from the applicant explaining the factual circumstances leading to the criminal offense(s); and
Letters from employers concerning work performance (specifically from nursing related employers, if possible).
The following information will be requested from the applicant with past disciplinary action or licensure/certification
denial in another state:



A certified copy of the Order for disciplinary action or denial from the other state licensing entity; and certified
copy of any subsequent actions (i.e. reinstatement), if applicable;
A letter from the applicant explaining the factual circumstances leading to the action or denial; and
Letters from employers concerning work performance (nursing related preferred) since action.
The following information may be requested from applicants with a possible impairment:




Evidence of any past treatment (i.e., discharge summary from outpatient treatment and inpatient
hospitalizations);
A letter from the applicant’s current treating healthcare provider(s) indicating diagnosis, treatment regimen,
compliance with treatment, and ability to practice safely;
A letter from the applicant explaining the factual circumstances of condition or impairment and addressing
ongoing efforts to function safely (including efforts to remain compliant with treatment, maintain sobriety,
attendance at AA/NA meetings, etc.); and
Letters from employers concerning work performance (specifically from nursing related employers, if possible).
NOTE: Some applicants may be eligible for the Health Practitioner’s Monitoring Program (HPMP),
which is a monitoring program for persons with impairments due to chemical dependency, mental health
or physical disabilities. Willingness to participate in the HPMP is information the Board of Nursing will
consider during the review process for applicants with a criminal conviction history related to
impairment or a history of impairment alone. Information about the Virginia HPMP may be obtained
directly from the DHP homepage at www.dhp.virginia.gov.
Once the Board of Nursing has received the necessary and relevant additional information, the application will be
considered. Some applicants may be approved based on review of the documentation provided. Other applicants may
be required to meet with Board of Nursing representative(s) for an informal fact finding conference to consider the
application. After the informal fact-finding conference, the application may be: i) approved, ii) approved with
conditions or terms, or iii) denied. The Board will notify the testing company directly of all applicants approved so that
testing may be scheduled. Upon notification of successful completion of the licensure or certification exam, the Board
of Nursing will license or certify the individual based on the Board’s Order, including any terms imposed for practice.
NOTE: Failure to reveal criminal convictions, past disciplinary actions, and/or possible impairment issues on any
application for licensure or certification is grounds for disciplinary action by the Board of Nursing, even after the
license or certificate has been issued. It is considered to be “fraud or deceit in procuring or attempting to procure
a license,” and a basis for disciplinary action that is separate from the underlying conviction, past action, or
impairment issue once discovered. Possible disciplinary actions that may be taken range from reprimand to
revocation of a license or certificate.
FOLLOWING LICENSURE OR CERTIFICATION
Criminal convictions and other actions can also affect an individual already licensed as a nurse or certified as a nurse
aide by the Board of Nursing. Any felony conviction, court adjudication of incompetence, or suspension or revocation of
a license or certificate held in another state will result in a “mandatory suspension” of the individual’s license, multistate privilege, or certificate to practice in Virginia. This is a nondiscretionary action taken by the Director of DHP,
rather than the Board of Nursing, according to § 54.1-2409 of the Code of Virginia. The mandatory suspension remains
in effect until the individual applies for reinstatement and appears at a formal hearing before at least a panel of the
Board of Nursing and demonstrates sufficient evidence that he or she is safe and competent to return to practice. At the
formal hearing, three quarters of the Board members present must agree to reinstate the individual to practice in order
for the license or certificate to be restored.
II. CRIMINAL CONVICTIONS AND EMPLOYMENT IN NURSING FACILITIES, HOME CARE,
HOSPICE AND ASSISTED LIVING FACILITIES3
According to §§ 32.1-126.01 and 32.1-162.9:1 of Title 32.1 and §§ 63.2-1719 and 63.2-1720 of Title 63.2 of the Code of
Virginia, persons with certain criminal convictions are prohibited from employment in nursing facilities, home care
organizations, hospice programs, or assisted living facilities, whether or not the person is licensed or certified by the
Board of Nursing. These convictions are commonly known as “barrier crimes” to employment.
The law requires that owners/operators of nursing facilities, home care organizations, hospice programs, and assisted
living facilities obtain a criminal record background check on each new hire within 30 days of their employment. The law
requires that these background checks be obtained using the Central Criminal Records Exchange of the Virginia
Department of State Police.
Generally, criminal convictions for offenses involving abuse or neglect disqualify an applicant. See a listing of the
“barrier” crimes that prevent employment in a nursing facility, home care organization, hospice program or assisted
living facility in the Appendix beginning on page 9.
Revised September 2006
CONVICTIONS THAT DO NOT DISQUALIFY
AN APPLICANT FROM EMPLOYMENT
Under Virginia law, criminal convictions for offenses unrelated to abuse or neglect would not disqualify an applicant for
employment. For example, criminal convictions such as traffic violations, possession of marijuana, and prostitution, may
not disqualify an applicant. However, these convictions may disqualify an applicant based on a particular employer’s
hiring or personnel policies, or based on other regulations or policies4.
Even if the applicant has been convicted of a barrier crime, it may not always prevent employment. An applicant may be
hired if:
(i) The individual has only one misdemeanor conviction considered to be a barrier crime;
(i) The criminal offense did NOT involve abuse or neglect; AND
(ii) Five years have lapsed since the conviction occurred.
Examples of such misdemeanor convictions that would not necessarily be a barrier to employment may include, but are
not limited to:
3
Individuals licensed or certified by the Board of Nursing may be eligible for employment in other health care settings, depending
upon the hiring and employment practices of the particular employer.
4
Such as federal Medicare or Medicaid certification regulations.

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
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





Hazing
Reckless handling of a firearm
Access to loaded firearm by children
Assault and battery
Assault and battery against law enforcement officers
Burning or destroying any other building, or structure valued less than $200
Burning or destroying personal property, standing grain, etc., valued less than $200
Threats to bomb or damage buildings or means of transportation, false information as to danger to such
buildings, etc. (if person is younger than 15 years of age)
Setting woods, etc, on fire intentionally whereby another is damaged or jeopardized
Setting off chemical bombs capable of producing smoke in certain public buildings
Carelessly damaging property by fire
DISCLOSURE OF CRIMINAL CONVICTIONS
If an applicant is denied employment because of convictions appearing on his criminal history record, the employer is
required to provide a copy of the information obtained from the Central Criminal Records Exchange to the applicant.
While further dissemination of the results of a criminal record check by an employer is prohibited, employers may
provide criminal record information and reason for employment termination to state authorities to comply with legal
reporting requirements.5 Criminal conviction information reported to the Board of Nursing that was not revealed by the
licensed nurse or C.N.A. upon initial application for licensure or certification may form the basis for disciplinary action to
be taken by the Board of Nursing. Disciplinary actions for such “fraud or deceit in procuring a license or certificate” or
for falsifying an employment application may range from reprimand to revocation of the license or certification.
Note: The law specifies that incomplete or false statements in an applicant’s sworn statement or affirmation
disclosing any criminal convictions or any pending criminal charges constitutes a misdemeanor offense.
Subsequent disclosure or discovery of a relevant criminal conviction or convictions may also disqualify the
person from being hired and from continuing on in the hired employment.
III. GETTING A CRIMINAL RECORD EXPUNGED
Having been granted a pardon, clemency, or having civil rights restored following a felony conviction does not change
the fact that a person has a criminal conviction. That conviction remains on the individual’s licensure/certification or
employment record. Therefore, any criminal conviction must be revealed on any application for licensing or
employment, unless it has been expunged.
Chapter 23.1 of Title 19.2 of the Code of Virginia describes the process for expunging criminal records. If a person wants
a conviction to be removed from their record, the individual must seek expungment pursuant to § 19.2-392.2 of the
Code of Virginia. Individuals should seek legal counsel to pursue this course, which involves specific petitions to the
court, State Police procedures, and hearings in court.
5
See § 54.1-2400.6 of the Code of Virginia for mandatory reporting requirements.
APPENDIX.
BARRIER CRIMES PROHIBITING EMPLOYMENT
IN NURSING HOME FACILITIES, HOME CARE ORGANIZATIONS,
HOSPICE PROGRAMS AND ASSISTED LIVING FACILITIES
NOTE: This list is not all-inclusive and should be used only as a guide. For further clarification regarding criminal
offenses, refer to Title 18.2 Crimes and Offenses Generally of the Code of Virginia.
State Code
Offense
18.2 - 30
Murder and manslaughter declared felonies
18.2 – 31
Capital murder defined
18.2 – 32
First and second degree murder defined
18.2 – 32.1
Murder of a pregnant woman
18.2 – 33
Felony homicide
18.2 – 35
How voluntary manslaughter punished
How involuntary manslaughter punished
18.2 – 36
Certain conduct punishable as involuntary manslaughter
18.2 –36.1
How and where homicide prosecuted and punished
18.2 – 37
Malicious wounding by a mob
18.2 – 41
Abduction
18.2 – 47
18.2 – 48
Abduction with intent to extort money or for immoral purposes
18.2 – 51
Shooting, stabbing, etc. with intent to maim, kill, etc.
18.2 - 51.1
Malicious bodily injury to law enforcement officers or firefighters
18.2 - 51.2
Aggravated malicious wounding
18.2 - 51.3
Reckless endangerment/throwing objects from places higher than one story
18.2 - 51.4
Maiming, etc., of another resulting from driving while intoxicated
18.2 - 52
Malicious bodily injury by means of caustic substance
18.2 - 52.1
Possession of infectious biological substances
State Code
Offense
18.2 – 53
Shooting, etc., in committing or attempting a felony
18.2 - 53.1
Use or display of firearm in committing felony
18.2 - 54.1
Attempts to poison
18.2 - 54.2
Alteration of food, drink, drugs, cosmetics, etc.
18.2 - 55
Bodily injuries caused by prisoners, probationers, or parolees
18.2 - 56
Hazing
18.2 - 56.1
Reckless handling of firearms
18.2 - 56.2
Allowing access to firearms by children
18.2 - 57
Assault and battery
18.2 - 57.01
18.2 - 57.2
Pointing a laser at law-enforcement officer
18.2 - 58
Robbery
18.2 - 58.1
Carjacking
18.2 – 60
Threats of death or bodily injury
18.2 – 60.3
Felony stalking
18.2 – 61
Rape
18.2 – 63
Carnal knowledge of child between 13 and 15 years of age
18.2 - 64.1
Carnal knowledge of certain minors
18.2 - 64.2
18.2 - 67.1
Carnal knowledge of inmate, parolee, probationer, or pre-trial or post-trial offender
18.2 - 67.2
Object sexual penetration
18.2 - 67.2:1
Marital sexual assault
18.2 - 67.3
Aggravated sexual battery
18.2 - 67.4
Sexual battery
18.2 - 67.4:1
18.2 - 67.5
Infected sexual battery
Assault and battery against a family or household member
Forcible sodomy
Attempted rape, forcible sodomy, object sexual penetration, aggravated sexual battery,
and sexual battery
State Code
Offense
18.2 – 77
Burning or destroying dwelling house, etc.
18.2 – 79
Burning or destroying meeting house, etc.
18.2 – 80
Burning or destroying any other building or structure (valued at $200 or more)
18.2 – 81
Burning or destroying personal property, standing grain, etc. (valued at $200 or more)
18.2 – 82
Burning building or structure while in such building or structure with intent to commit
felony
18.2 – 83
Threats to bomb or damage buildings or means of transportation, false information as to
danger to such buildings, etc. (if person is older than 15 years of age)
18.2 – 84
Causing, inciting, etc., commission or acts described in 18.2 - 83 (if person is older than 15
years of age)
18.2 – 85
Manufacture, possession, use, etc. of fire bombs or explosive material or devices
18.2 - 86
Setting fire to woods, fences, grass, etc.
18.2 - 87
Setting woods, etc. on fire intentionally, where another’s property is damaged or
jeopardized
18.2 - 87.1
18.2 - 88
18.2 – 286.1
18.2 – 289
Setting of chemical bombs capable of producing smoke in certain public buildings
Carelessly damaging property by fire
Drive by shooting
Use of a machine gun in a crime of violence
18.2 – 290
Aggressive use of a machine gun
18.2 - 300
Use of a sawed-off shotgun in a crime of violence
18.2 - 314
Failing to secure medical attention for injured child
18.2 - 355
Pandering, taking, detaining, etc., person for prostitution, etc., or consenting thereto
18.2 – 361
Crimes against nature involving children
18.2 - 366
Incest
18.2 - 369
Abuse and neglect of incapacitated adults
18.2 - 370
Taking indecent liberties with children
18.2 - 370.1
Taking indecent liberties with child by person in custodial or supervisory relationship
State Code
Offense
18.2 - 371.1
Abuse and neglect of children
18.2 – 373
Obscene items enumerated
18.2 - 374
Production, publication, sale, possession, etc., of obscene items
18.2 - 374.1
Production, publication, sale, possession with intent to distribute, financing, etc., of
sexually explicit items involving children
18.2 – 374.1:1
18.2 – 374.3
Possession of child pornography
Electronic facilitation of pornography
18.2 – 375
Obscene exhibitions and performances
18.2 - 376
Advertising, etc., obscene items, exhibitions or performances
18.2 – 376.1
Enhanced penalties for using a computer in certain violations
18.2 - 377
Placards, posters, bills, etc.
18.2 – 378
Coercing acceptance of obscene articles or publications
18.2 - 379
Employing or permitting minor to assist in offense under article.
18.2 – 474.1
Delivery of drugs to prisoners
18.2 – 477
Escape from jail
53.1 - 203
Felonies by prisoners
Equivalent offense in another state
(Guidance Document 90-55 signature page)
I have received a copy of applicable law regarding criminal history
checks and a list of barrier crimes (Guidance Document 90-55). By signing
I acknowledge that I have received, read, and understand how
convictions and other past history may affect the application process and
subsequent licensure or certification by the Board of Nursing.
Student Name: _______________________________
Date: ___________________________
Consumer Disclosure and Authorization Form
Disclosure Regarding Background Investigation
Raspberry Hill Adult Daytime Center
may request, for lawful
employment purposes, background information about you from a consumer reporting agency in connection with your
employment or application for employment (including independent contractor assignments as applicable). This
background information may be obtained in the form of consumer reports and/or investigative consumer reports
(commonly known as “background reports”). These background reports may be obtained at any time after receipt of your
authorization and, if you are hired or engaged by The Company, throughout your employment or your contract period.
Backgrounds Online will prepare or assemble the background checks for the Company. Backgrounds Online is located
and can be contacted by mail at 1915 21 st Street, Sacramento, California 95811, and by phone at 800-838-4804. Their
website can be found at http://www.backgroundsonline.com.
The types of information that may be obtained include, but are not limited to: social security number verifications,
address history, credit reports and history; criminal records and history; public court records; driving records; worker’s
compensation claims, bankruptcy filings; educational history verifications (such as dates of attendance and/or degrees
obtained); employment history verifications (such as dates of employment, salary, reasons for termination, etc); personal
and professional reference interviews; professional licensing and certific ation checks; drug/alcohol testing results; and
other information bearing on your character, general reputation, personal characteristics, mode of living and credit
standing.
This information may be obtained from private and public record sources, includ ing, as appropriate: government agencies
and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends
and associates and other information sources.
You may request more information about the nature and scope of any investigative consumer reports by contacting The
Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.
Additional State Law Notices
If you are a California, Maine, Massachusetts, New York or Washington applicant, employee or contractor, please also
note:
California: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by
Backgrounds Online during normal business hours. You may also obtain a copy of this file upon submitting proper
identification and paying the costs of duplication services, by appearing at Backgrounds Online’s offices in person, during
normal business hours and on reasonable notice, by mail. You may also receive a summary of the file by telephone,
upon submitting proper identification. Backgrounds Online has trained personnel available to explain your file to you,
including any coded information. If you appear in person, you may be accompanied by one other person, provided tha t
person furnishes proper identification.
Maine: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and
if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request
and receive from The Company, within five business days of our receipt of your request, the name, address and
telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an
investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive
from all such agencies copies of any reports.
Massachusetts: If we request an investigative consumer report, you have the right, upon written request, to a copy of the
report.
New York: You have the right, upon request to be informed of whether or not a consumer report was requested. If a
consumer report is requested, you will be provided with the name and address of the consumer reporting agency
furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Attached below is
additional information about New York law.
Washington: If The Company requests an investigative consumer report, you have the right, upon written request made
within a reasonable period of time after your receipt of this disclosure, to receive from The Company a complete and
accurate disclosure of the nature and scope of the investigation requested by The Company. You also have the right to
request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair
Credit Reporting Act.
REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION
PLEASE TYPE OR PRINT
I:
________________________________________________________________________________________
LAST NAME
FIRST NAME
MIDDLE NAME
(PLEASE INCLUDE Jr., Sr., II, III Etc.)
Have carefully read and understand this Disclosure and Authorization form as well as the attached Summary of Rights under the Fair Credit
Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as Backgrounds
Online, and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of
assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as
applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my
services, my consent will apply, and the Company may obtain background reports throughout my employment or contract period.
I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my
employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also
understand that nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service
bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present
employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting
agency.
By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that
this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be
requested by or on behalf of the company.
California, Minnesota and Oklahoma Applicants only:
Check box if you request a copy of any consumer report ordered on you.
LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING
INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES.
__________
Signed
__________
Today’s Date
__________
__________
Printed Name
Position Applied For
_______---_____---________
____/_____/____
Social Security Number
Date of Birth
________________
Driver’s License Number
State
Other names you have used or are also known as:
PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS
Current Address: _________________________________________________________________________________________________________
Street
Apt.#
City
State
Zip Code
How long here?
Former Address: _________________________________________________________________________________________________________
Street
Apt.#
City
State
Zip Code
How long here?
Former Address: _________________________________________________________________________________________________________
Street
Apt.#
May we contact your current employer?
City
Yes
State
Zip Code
How long here?
No
Applicants under 18 years of age must have a parent or court appoint guardian sign this Authorization of Background Investigation
Parental Consent: I hereby give my consent for the above-mentioned applicant to have a background check performed on him/her. Furthermore, I hereby
understand and agree to the conditions of this Release as described above.
____________________________________________________________
________________________________________________________
Parent/Guardian Signature
Date
Parent/Guardian Name
Summary of Consumer Rights
Under the Fair Credit Reporting Act
Para información en español, visite www.consumerfinance.gov/learnmore o escriba a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of
consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty
agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here
is a summary of your major rights under the FCRA. For more information, including information about additional rights, go
to: www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W.,
Washington, DC 20552.
• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of
consumer report to deny your application for credit, insurance, or employment—or to take another adverse action against you—
must tell you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a
consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your
Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:





a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit
bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional
information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on
information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or
distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will
receive credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete
or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate,
incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting
agency may continue to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency
may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need
-- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those
with a valid need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out
information about you to your employer, or a potential employer, without your written consent given to the employer. Written
consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.
Unsolicited “prescreened offers” for credit and insurance must include a toll-free phone number you can call if you choose to
remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at
1-888-567-8688.
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a
furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.consumerfinance.gov/learnmore.
TYPE OF BUSINESS:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates
b. Such affiliates that are not banks, savings associations, or
credit unions also should list, in addition to the CFPB:
CONTACT:
a. Consumer Financial Protection Bureau
1700 G Street NW
Washington, DC 20552
b. Federal Trade Commission: Consumer
Response Center--FCRA
Washington, DC 20580
(877) 382- 4357
a. Office of the Comptroller of the Currency
Customer Assistance Group
2. To the extent not included in item 1 above:
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
a. National banks, federal savings associations, and federal
branches and federal agencies of foreign banks
b. Federal Reserve Consumer Help Center
P.O. Box 1200
b. State member banks, branches and agencies of foreign
banks (other than federal branches, federal agencies, and
Insured State Branches of Foreign Banks), commercial
lending companies owned or controlled by foreign banks, and
organizations operating under section 25 or 25A of the
Federal Reserve Act
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
c. Nonmember Insured Banks, Insured State Branches of
Foreign
Banks, and insured state savings associations
d. National Credit Union Administration
Office of Consumer Protection (OCP)
d. Federal Credit Unions
Division of Consumer Compliance and Outreach
(DCCO)
1775 Duke Street
Alexandria, VA 22314
Asst. General Counsel for Aviation Enforcement &
Proceedings
Aviation Consumer Protection Division
3. Air carriers
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
Office of Proceedings, Surface Transportation
Board
4. Creditors Subject to the Surface Transportation Board
Department of Transportation
395 E. Street, S.W.
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration
area supervisor
Associate Deputy Administrator for Capital Access
United States Small Business Administration
6. Small Business Investment Companies
409 Third Street, SW, 8th Floor
Washington, DC 20416
Securities and Exchange Commission
7. Brokers and Dealers
100 F St., N.E.
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations,
Federal
Intermediate Credit Banks, and Production Credit
Associations
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
FTC Regional Office for region in which the creditor
operates or
9. Retailers, Finance Companies, and All Other Creditors Not
Listed Above
Federal Trade Commission: Consumer Response
Center – FCRA
Washington, DC 20580
(877) 382-4357
States may enforce the FCRA, and many states have their own consumer reporting laws. In some
cases, you may have more rights under state law. For more information, contact your state or local
consumer protection agency or your state Attorney General. For information about your federal
rights, contact:
New York Article 23-A Correction Law
§ 750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department,
agency, board or commission. (2) "Private employer" means any person, company, corporation, labor
organization or association which employs ten or more persons. (3) "Direct relationship" means that the
nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability
to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job
in question. (4) "License" means any certificate, license, permit or grant of permission required by the laws
of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any
occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall
not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any
explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) "Employment" means any occupation,
vocation or employment, or any form of vocational or educational training. Provided, however, that
"employment" shall not, for the purposes of this article, include membership in any law enforcement
agency.
§ 751. Applicability. The provisions of this article shall apply to any application by any person for a license
or employment at any public or private employer, who has previously been convicted of one or more
criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any
person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded
such employment or granting of a license, except where a mandatory forfeiture, disability or bar to
employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from
disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an
employer may have with respect to an intentional misrepresentation in connection with an application for
employment made by a prospective employee or previously made by a current employee.
§ 752. Unfair discrimination against persons previously convicted of one or more criminal offenses
prohibited. No application for any license or employment, and no employment or license held by an
individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by
reason of the individual's having been previously convicted of one or more criminal offenses, or by reason
of a finding of lack of "good moral character" when such finding is based upon the fact that the individual
has previously been convicted of one or more criminal offenses, unless:
(1) there is a direct relationship between one or more of the previous criminal offenses and the
specific license or
employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment
would involve an
unreasonable risk to property or to the safety or welfare of specific individuals or the
general public.
§ 753. Factors to be considered concerning a previous criminal conviction; presumption. 1. In
making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or
private employer shall consider the following factors: (a) The public policy of this state, as expressed in this
act, to encourage the licensure and employment of persons previously convicted of one or more criminal
offenses. (b) The specific duties and responsibilities necessarily related to the license or employment
sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person
was previously convicted will have on his fitness or ability to perform one or more such duties or
responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness
of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard
to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer
in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making
a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private
employer shall also give consideration to a certificate of relief from disabilities or a certificate of good
conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to
the offense or offenses specified therein.
§ 754. Written statement upon denial of license or employment. At the request of any person
previously convicted of one or more criminal offenses who has been denied a license or employment, a
public agency or private employer shall provide, within thirty days of a request, a written statement setting
forth the reasons for such denial.
§ 755. Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be
enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2.
In relation to actions by private employers, the provisions of this article shall be enforceable by the division
of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and,
concurrently, by the New York city commission on human rights.
PLEASE apply early for Financial Aid!
Important!
* PAYPAL CREDIT
If you qualify it works like a credit card but for 6 months you have and NO interest, NO payment. But the
goal is to give help with upfront cost, get through the class, pass state boards and pay back as soon as
possible and then you wouldn't lose any money on interest.
If you already have an account with PayPal go to our website www.Raspberryhilladc.com and choose the
class you plan to attend, click "make a payment" and at check out choose "PayPal Credit" to pay for the
class. If you don’t have a PayPal account go to PayPal and create an account and apply for the PayPal
Credit first to see if you qualify (only takes a couple of minutes to see if you qualify) and then go to our
website and choose the classes you want.
____________________________________________________________
 Pay half down (Tuition) and half at Graduation! NO Interest! Call
Raspberry Hill HealthCare Training for this option! 434-525-4422
____________________________________________________________
 For possible FINANCIAL AIDE::
 Contacting Region 2000 Workforce Center:
o 434-455-5940 EXT.161
o Alvin D. Jones WIOA Program Coordinator
o *Tell them you are interested in doing Raspberry Hill Adult Daytime
Center’s Nurse Aide Program, how can you apply for financial aid.
You will have to fill out an application and attend an Orientation.
APPLY EARLY AS POSSIBLE!
_____________________________________________________________
 *Monika Christian, GoodCare Coach, Workforce Development
434-200-9920 ext. 6114 174 River James Shopping Center, Madison
Heights, VA 24572
 Or Call 1-540-581-0620 ext. 1219 www.goodwillvalleys.com
____________________________________________________________
 Your local Social Service Department for vocational training assistance. If
you receive TANF you are probably eligible for education assistance.
 The local DARS 2250 Murrell Rd. #F, Lynchburg VA. 24501
o 434-947-6721 Lynchburg 1-800-552-5019. If you have any
disability(wide range including depression). You may apply for
vocational assistance after you file with a case manager with DARS.
____________________________________________________________
 Eligible Spouses who are surviving spouses of military personnel who died
in the line of duty after September 10, 2001. Prior to this only children of
those who died in the line of duty were eligible for this benefit.
www.gibill.va.gov; 1-888-GIBILL-1( 1-888-442-4551)
____________________________________________________________
 Or you may want to check with your current employer to see if they
have a reimbursement plan available.
____________________________________________________________
 Avante’ in Lynchburg will reimburse your tuition if you get hired
and work for a year after you complete the program. Call Avante’
and speak to Nathan Libassi, 434-846-8437
Great Job opportunities exist for Nurse Aide in Virginia! Visiting Angels
of Lynchburg, Generation Solutions, Centra Oakwood Manor in Bedford,
Avante in Lynchburg’, Westminster Canterbury of Lynchburg, First
Dominion HomeCare Lynchburg, to name a few!
Thank you for your interest!
Healthcare Training
“We don’t make your career… we make it better!”
300 Enterprise Drive Suite B, Forest, VA 24551
Web: www.RaspberryHilladc.com Email: [email protected]
Facebook: www.facebook.com/raspberryhill.adultdaycenter
Tuition Fee: (Includes Textbook, Student Workbook, and Board of Nursing Curriculum
Book) ...$795.00.
* Full Tuition is DUE BEFORE Orientation day. Invoice will be sent out if you
are accepted into the program.
*Application Fee $10.00 Due with application. (non-refundable)
*Background check $30.00 Due with application. (non-refundable)
HCP BLS CPR (Discounted price , Must have before class starts)------- $40.00
NNAAP EXAM FEE------------ $94.00 (State Board Exam) Student Registers after course
completion.
*You will need to purchase uniforms, stethoscope,white shoes, etc. SEE CHECKLIST!
*Tuition includes Course, books, curriculum, name badge, certificate/holder.
Tuition Refund Policy: All classes

Nurse Aide/68 Medication Aide Program/PCA, 32hr Medication Aide, First Aide, CPR, Direct Client Course: *Payment is
DUE for classes upon acceptance into the program except CPR and First Aid. You will receive a letter of acceptance
into these programs and an invoice will be sent out for balance DUE. This amount must be received by DUE date or your
spot will be filled by another candidate.

*Unless further arrangements have been made through DARS, GoodCare, Region 2000, or payment plan option through
Raspberry Hill ADC.

*Cancellations must be written 14 days in advance before the beginning of the 1st day of class in order to get a refund on
the class tuition. If you cancel after the 14 day notice in advance you will not receive a REFUND on any portion. Your spot
was reserved and cannot be replaced at the last minute. Thank you.
PHOTO RELEASE
I, (student’s name)_____________________________________________ give my
permission for Raspberry Hill Adult Daytime Center to use a picture or video taken of
Education Classes (Personal Care Aide, Certified Nursing Assistant ,Medication Aide, CPR,
First Aid, that are done at Raspberry Hill Adult Daytime Center for the following use:
Pictures and Videos taken by Raspberry Hill Adult Daytime Center will be posted on the
Raspberry Hill Adult Daytime Center Face book page, or website of Raspberry Hill Adult
Daytime Center, www.Raspberryhilladc.com. These pictures/videos will be for the sole
purpose of demonstrating the Education classes and promoting them to the Community.
For good and valuable consideration and intending to be legally bound hereby, the
undersigned agrees and consents that any photographs, films, videotapes, voice recordings
and/or testimonials of her or him, taken or made by may in any manner be used, published,
displayed, dealt in and copyrighted by the organization, and that all materials and rights
connected herewith are the exclusive property of Raspberry Hill Adult Day Time Center.
The undersigned further agrees to release for herself or himself their heirs, executors and
administrators of its officers, agents, employees, advertising agents, successors and
assignees, from any obligation or liability and from any and all claims for libel, slander,
invasion of privacy, compensation or any other claims based on the use or exhibition of said
material.
Signature: _____________________________________________
Date:_________________________________________________
Witness Signature:_______________________________________
Date:__________________________________________________
Nurse Aide Check list
__Application sent
__Barrier Crime information sheet read and signed and dated. (due with application)
__Disclosure Form signed and dated. (due with application)
__Application Fee $10.00 (due with application)
__Background Check Fee $30.00
__Tuition Fee $795.00 (due before Orientation Day) invoice will be sent
__Copy of Drivers License or ID (due by Orientation Day)
__Copy of Immunization Records, Hep B, MMR, Varicella Vaccine (Chicken pox) (due by Orientation Day)
__Flu Vaccine (October-April season only).
__TB test within 30 days of attendance (due by Orientation Day)
__Photo Release Form signed (due by Orientation Day)
__Copy of current Healthcare Provider BLS CPR/AED adult/child/infant certification card (due by 1st day of
class)
__Signed signature page that you have read Student Handbook (due by Orientation Day)
__Signed Student Clinical Agreement for Avante’ (will do on Orientation Day)
__Signed Avante’/Westminster Neglect & Abuse in-service documentation (will do on Orientation Day)
Supplies needed for class
__Burgundy scrub top/bottom (2 pair recommended)
__Stethoscope
__White closed toed shoes (clean Tennis Shoes ok)
__Second hand watch
__Paper, Pens, Pencils, Highlighters, etc
__Blood Pressure Cuff (Optional)