AFFLIATION PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA
|
|
- Amy Bates
- 5 years ago
- Views:
Transcription
1 AFFLIATION PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA
2 PEACEHEALTH STANDARDS FOR COMPLIANCE PeaceHealth Mission: At PeaceHealth, the fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family. This information has been developed to assist you with a process essential for ensuring that everyone accepted into PeaceHealth have met the necessary requirements. TABLE OF CONTENTS PAGE 1. Clinical Affiliation Agreement 1 2. Criminal Background Check a. Process 1-2 b. Matrix 2-3 c. Contact information to set up an account 3 3. Health Screen a. Process 3-4 b. Contact information to set up an account 3 4. Confidentiality Agreement a. Process 4 5. Orientation Manual a. Process 4 b. Test Answer Score Sheets Liability Insurance 4 7. Confirmation of Standards Checklist a. Process 5 b. Checklist form 6 8. Curriculum 5 9. Badge 5
3 CLINICAL AFFILIATION AGREEMENT A Clinical Affiliation Agreement must be secured prior to an Intern/Extern s acceptance into PeaceHealth, St. John Medical Center. To coordinate the Agreement you will need to contact our Contract Management Department at (360) CRIMINAL BACKGROUND INVESTIGATIONS 1.a. A criminal background must be completed by the school for all individuals. If criminal background checks are not standard for your company, PeaceHealth can help connect you to the service currently being utilized. (Refer to 1.c.) Each category must be completed as follows: Cowlitz County/Washington State Investigation: This search provides felony and misdemeanor arrests/convictions located at the county of the state in which the charge was brought and tried. Examples of criminal records include theft, assault, robbery, drug possession and murder. State Investigation: Conduct a statewide record search for felony and misdemeanor convictions for all applicable state/county lived in for the past 7 years. Social Security Check: This search can determine the following crucial information (a) whether the Social Security Number (SSN) is validly issued (b) to whom does the SSN belong (c) in which year and state the SSN was issued (d) the current and other known or previous addresses to that SSN. The SSN Verification process can reveal that the number belongs to another individual, has more than one name associated therewith, produces other aliases, including maiden and divorced names, is associated with fraud, is not a validly issued SSN, belongs to a deceased person, produces additional addresses not stated by the application/request form, or has other SSN s associated with that individual. FACIS: The Fraud & Abuse Control Information System health care data repository reports on disciplinary actions and sanctions at all levels of government, including the Offices of Inspectors General, the Department of Justice, Medicaid Fraud Control Units, state health departments and other quality assurance agencies. Professional License/Drivers License/Certification (If applicable by position): A search of the State or national licensing board or agency to verify a license type, license number, status, original issue date and other available information. NOTE: When the tests are successfully completed, mark appropriate box on the Confirmation of Standards checklist 1.b. Page 1 Matrix: 1. Refer to Matrix for disqualifiers. If there is criminal activity equaling 30 or greater points or the activity is congruent with the essential function of the position, this person would not be acceptable for work. Example: (if a person has a criminal history of Theft/Larceny, we wouldn t have them in our Payroll department even though the points don t equal 30.)
4 MATRIX TYPE OF CRIME OCCURRENCE LESS THAN 3 YEAR AGO CONVICTION OCCURRENCE 3 OR MORE YEARS CONVICTION Abduction *Abuse *Abuse of Corpse *Accessory to a crime Alcohol Violation (Driving, Public Nuisance, Minor, Etc) *Armed Robbery *Arson Assault/Battery *Assault with intent to murder Bad Check 10 5 Blocking a Medical Facility *Breaking and Entering *Bribery *Burglary *Child Prostitute *Coercion or Intimidation Controlled/Dangerous Substances (drugs) Conveying false information and threats *Credit Card Fraud Cruelty to animals Destruction of Property Driving Unlawfully *Embezzlement *Escape *Extortion False Alarms *Forgery/Counterfeiting Gaming Handgun Violations *Harboring a Fugitive *Harassment/Stalking *Hate Crimes *Incest *Impersonation of Police Officer Indecent Exposure *Kidnapping *Maiming *Murder Obscene Matter *Obstruction of Justice *Perjury Page 2
5 *Poison Prostitution *Racketeering *Rape or Sexual Abuse Receiving Stolen Goods *Robbery Rogue/Vagabond Theft/Larceny Trespassing Unlawful Possession, Use, Sale, Distribution, or manufacture of a Weapon Welfare Fraud Any conviction for an attempt, solicitation or conspiracy to commit any crime listed above is assigned the same value as a conviction for that crime. *A conviction for this crime(s) (if assigned a value of 30) is an absolute bar to the facility. 1.c. Criminal Background Company: As an agency affiliated with PeaceHealth we would like to offer you contact names to obtain the Criminal Background Checks and the Health Screens. If you choose to utilize these contacts you will have the opportunity to take advantage of our Corporate rates. (You are not required to use these contacts as long as the organizations that you utilize maintain our standards.) If you have any questions please call Intern Coordinator at (360) Kroll Background America, Inc 1900 Church St., Suite 400 Nashville, TN Contact Name: Raymond Jacobs x268 (Mention PeaceHealth Corporate rate to Raymond to receive our corporate discount.) HEALTH SCREEN REQUIREMENT Health screens may be conducted through our Workplace Wellness facility. You are not required to use our facility as long as the standard of compliance is met. If you would like to utilize our facility please call Workplace Wellness at to set up an appointment. A health screen must be completed prior to reporting to work to include: (If these standards have been completed as part of your requirements as an employer, retesting is not necessary as long as they meet PeaceHealth Standards.) NOTE: Tuberculosis test (TB) UA (Drug screen) - TEST MUST BE A NON-NIDA PERFORMED BY A CERTIFIED PROFESSIONAL COLLECTOR. Immunization background to be Measels, Mumps, Rubela, and Chicken Pox. The school must receive a copy of the results from the collection site. When the above requirements are successfully completed, check the appropriate box on the Confirmation of Standards checklist form. Page 3
6 CONFIDENTIALITY AGREEMENT A copy of the PeaceHealth Confidentiality Agreement has been provided in the orientation manual. The student must read and sign the confidentiality agreement. Keep this document in the student file at the school. NOTE: When the student has completed this requirement and returned the form to you, check the appropriate box on Confirmation of Standards checklist. ORIENTATION Each student must complete the Orientation Manual section. Testing is to be completed by the student. All tests must be completed and successfully passed, scoring keys have been included. Tests must be scored by the school personnel coordinating the internship placement. Keep a copy in the student file. NOTE: When the tests are successfully completed, mark appropriate box on the Confirmation of Standards checklist. LIABILITY INSURANCE The student must be covered by liability insurance prior to starting the intern/externship. Proof of Liability insurance must be met either by: Self insured (A copy of the insurance policy must be provided to PeaceHealth) School carries insurance (covered under contract) Amount of Insurance to be maintained for duration of Internship: Minimum of $1,000,000 per occurrence $3,000,000 in the aggregate NOTE: Check the appropriate box on Confirmation of Standards checklist. Page 4
7 CURRICULUM A copy of a Curriculum must be presented to the PeaceHealth department manager at time of starting the internship. This will help us meet the needs of the student. BADGE Students must bring their school pictured identification badge with them upon their first day. CONFIRMATION OF STANDARDS The Confirmation of Standards checklist indicates that all phases have been successfully completed maintaining PeaceHealth standards. Once the list is complete, the school needs to fax copy to PeaceHealth, Human Resources, fax # located on the Confirmation of Standards checklist. Page 5
8 CONFIRMATION OF STANDARDS CHECKLIST INTERN/EXTERN NAME OF SCHOOL: NAME OF STUDENT: meets the standard requirements for PeaceHealth. If at any time the contracted employees status changes, regarding any type of infraction, PeaceHealth will be notified immediately and termination could/will occur. These steps must be completed and standards are within compliance agreed upon by PeaceHealth and School prior to starting Internship. It is the responsibility of the school to process and maintain requirements PeaceHealth has requested. [] Criminal Background Check, refer to Matrix for standards. PeaceHealth must receive a copy from the school, via fax, of this document along with the Confirmation of Standards. [] State/County Investigation in which person has lived for the past 7 years []Washington State Investigation [] Social Security Check [] Professional License (If applicable) [] F.A.C.I.S. (to include MEDICARE FRAUD & ABUSE) [] Health Screen (Completed and results are favorable staying within PeaceHealth standards) [] Tuberculosis Test (TB) (Must have yearly test to maintain clearance, results must be reported to PeaceHealth) [] UA (Drug screen) (Will participate in our Drug Free Workplace Program) [] Immunization background [] Insurance Coverage (Please identify how the student is covered.) [] Self insured (A copy of the insurance policy must be provided to PeaceHealth) [] School carries insurance (covered under contract) [] Licensure/Certification (Washington State) (Must have evidence of valid licensure if required for internship.) [] Confidentiality Agreement (PeaceHealth, located in the Orientation Manual ) [] Orientation Manual (Must be successfully completed) [] Curriculum (A copy of the Student Curriculum must be presented to PeaceHealth) **Please return Confirmation of Standards checklist to PeaceHealth Representative so authorization can be given to begin Internship. (Attn: Michele Wagner phone #: , Fax information to ) Representative Signature: Date PeaceHealth Rep.Signature: Date PeaceHealth Dept/Mngr Signature: Date Page 6
9 TEST ANSWER SCORE SHEETS Organizational Integrity Test Answers Instructions: Please complete the following quiz, sign, and return this document to your supervisor 1. At PeaceHealth, our Standard of Conduct is based on what? Answer: Mission and Values 2. In your own words, what does PeaceHealth's Non-retaliation/Non-retribution policy say? Answer: No action will be taken against me for asking questions regarding Integrity or reporting behaviors that are not in keeping with the Integrity policies of the organization. 3. What is the PeaceHealth Integrity Line? Answer: A contact service available 24 hours a day, 7 days a week that an employee can call to report concerns about actual or potential wrongdoing or ask for clarification regarding an Integrity issue. 4. True or False: The Office of the Inspector General could fine PeaceHealth for hiring or doing business with an individual or organization on the Excluded List. (Circle the right choice) TRUE 5. True or False: PeaceHealth's Organizational Integrity program covers only policies having to do with billing and confidentiality. (Circle the right choice) FALSE 6. True or False: You have a responsibility to report in good faith, concerns about actual or potential wrongdoing and are not permitted to overlook such situations (Circle the right choice) TRUE Page 7
10 Confidentiality Test & Acknowledgement Instructions: Please complete the following quiz, sign, and return to your supervisor. 1. Write down two examples of specific rights every patient has regarding his or her health information? Any of the following: Right to request access, inspect and copy health information Right to a Notice of PeaceHealth s Privacy Practices Right to request an amendment to their health information Right to request restrictions to the use and disclosure of their health information Right to an accounting of the disclosures made of their health information 2. What telephone # would you call to contact your Regional Privacy Officer? extension Where is the PeaceHealth Privacy and Security Policy Manual located? On the Crossroads Policy Center or on the Organizational Integrity website on Crossroads 4. Define the term minimum necessary as it relates to confidential information. Disclosure of confidential information should be limited to the minimum necessary to meet the need. A request for disclosure of the entire medical record must be justified. 5. Why is it important to identify and question unfamiliar individuals (that is, those who apparently don t belong) in your work area? For the safety of our patient and employees and for the protection of our confidential information. 6. Can a breach of confidentiality be grounds for termination? YES 7. If I overhear a conversation outside the clinical area regarding sensitive patient information, should I let the offenders know immediately that they are violating the confidentiality policy? YES 8. Should I access a medical record (other than my own) for any reason other than a work-related purpose (need-to-know)? NO Page 8
11 Safety Basics Test Instructions: Please complete the following quiz and return this document to your supervisor 1. In which of the following scenarios should you contact Infection Control? a. You suspect a patient has Influenza. b. You initiate airborne precautions for a suspected TB patient. c. Some you live with acquires Chickenpox. 2. Why is it important to notify Infection Control within 1-2 hours if you've had a blood borne pathogen exposure? HIV Infection may be prevented with appropriate medication if initiated within 1-2 hours of the time of injury. 3. How do you call a code? a. Dial 911 b. Dial 4199 and explain situation and location c. None of the above 4. A Trauma or Modified Trauma is announced when confirmed disaster victims begin arriving at the Emergency Department. a. True b. False 5. During a Disaster where do you check in for job assignment if you do not have patient care duties? a. Medical Library b. Health Education Center c. Department Manager 6. Define each step in the RACE procedure. R RESCUE A ALARM C CONTAIN E EXTINQUISH 7. What does the acronym PASS stand for when using a fire extinguisher? Pull, Aim, Squeeze, Sweep 8. A CODE is paged overhead to announce a fire or fire drill. Code Red Page 9
12 Safety Basics Test 9. Match the following codes with their definitions. F Code Orange C Code Gray H Code Red E Code Pink D Level I, II or III Internal Disaster G Code Purple B Code 6 A Code Blue A. cardiopulmonary arrest B. person out of control C. First Responders needed D. large chemical spill E. infant/child abduction F. bomb threat G. hostage/weapons threat H. fire 10. The Incident Report can only be found on-line. a. True b. False 11. Describe the steps to be followed if you discover an unsafe medical device? Immediately discontinue use of the equipment Save all equipment and packaging which may include lot numbers involved in the event Clearly mark the device and equipment as defective with a red tag Complete an electronic work order on Crossroads If immediate replacement is needed, contact customer service at What type of equipment should be sent to Maintenance for repair? Non-Clinical Equipment 13. When should switchboard be notified in the event of a hazardous spill? c. If it cannot be cleaned up by the department 14. Name one location where you can find a spill kit. In Your Department 15. Where can you find information about a chemical? a. MSDS b. Container label c. Safety office d. All of the above Page 10
13 Safety Basics Test 16. Workplace violence can be defined as any behavior that you perceive as threatening. a. True b. False 17. Signs of anxiety are usually displayed before signs of aggression. a. True b. False 18. You ve tried a combination of different interventions in an attempt to calm an anxious client. However, the client is becoming more and more frustrated and starts using loud, threatening language. What should be your very first action? a. Try another attempt at using the interventions for dealing with anxiety b. Establish proper space (at least 4 feet between yourself and the aggressor) c. Call Security or 911 Page 11
14
INSTRUCTIONS FOR SCHOOL. PLACEMENT PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA
INSTRUCTIONS FOR SCHOOL PLACEMENT PROCESS (Internship/Externship) PEACEHEALTH ST. JOHN MEDICAL CENTER LONGVIEW, WA 2 Requesting School Directions 1. Request for student placement made to St. John Learning
More informationNIMS Credentialing Criteria for CERTs
NIMS Credentialing Criteria for CERTs The following criteria are effective as of August 17, 2015. Criteria will be reviewed regularly and revised as needed. To receive a PIV-I (Personal Identity Verification-Interoperable)
More informationInformation in State statutes and regulations relevant to the National Background Check Program: Arkansas
Information in State statutes and regulations relevant to the National Background Check Program: Arkansas This document describes what was included as of December 2010 in Arkansas statutes and regulations
More informationNURSING REVIEW BOARD
NURSING REVIEW BOARD I. Introduction The following procedure outlines the process to be followed in all cases where criminal findings are found in the background checks for prospective and current Nursing
More informationInternship Application x2645
Internship Application 978-683-4000 x2645 Office Use Only Application Received Interview Orientation CORI TB1 TB2 Pin # Entered in Volgistics FLU PERSONAL INFORMATION First Name Last Name Street Address
More informationPolicy S-2 FLORIDA STATE UNIVERSITY COLLEGE OF NURSING Page 1 of 2 TITLE: CRIMINAL BACKGROUND CHECK
Policy S-2 FLORIDA STATE UNIVERSITY COLLEGE OF NURSING Page 1 of 2 TITLE: POLICY: CRIMINAL BACKGROUND CHECK The College of Nursing requires all students to have a Criminal Background Check on file at the
More informationNo AN ACT. Providing for Statewide nurse aide training programs relating to nursing facilities.
SESSION OF 1997 Act 1997-14 169 HB 133 No. 1997-14 AN ACT Providing for Statewide nurse aide training programs relating to nursing facilities. The General Assembly finds and declares that nurse aides in
More informationStreet Address City State Zip
Champlain Enterprises, Inc. Application for Employment 24950 Country Club Blvd. Suite 300, rth Olmsted, OH 44070 An Equal Opportunity Employer All applications will remain active for one year from the
More informationStreet Address City State Zip
Champlain Enterprises, Inc. Application for Employment 24950 Country Club Blvd. Suite 300, rth Olmsted, OH 44070 An Equal Opportunity Employer Operated by CommutAir All applications will remain active
More informationHow to Apply. Volunteer Services. Becoming a volunteer. Requirements. Training. Uniform. Apply today!
Volunteer Services How to Apply Becoming a volunteer We invite you to join our team! To pursue a volunteer position at Providence, here are the steps you need to take: 1. Fill out the application and return
More informationVolunteer Application Packet
Volunteer Application Packet Thank you for your interest in the TechTutor Volunteer Program. This Application Packet contains the Application Checklist, and Request for Criminal History & Disclosure forms.
More informationInformation in State statutes and regulations relevant to the National Background Check Program: Washington
Information in State statutes and regulations relevant to the National Background Check Program: Washington This document describes what was included as of February 2011 in Washington statutes and regulations
More informationStudent Orientation Post-Assessment
Name Date Student Orientation Post-Assessment Print, answer questions and bring with you to Education Resources at Penrose Hospital. 1. List two (2) of the seven (7) Centura Core Values and describe their
More informationL Ecole Culinaire Memphis
2011 ANNUAL SECURITY REPORT Campus security and safety are important issues in postsecondary education today. In recognition of this fact, and in keeping with applicable federal requirements, L Ecole Culinaire
More informationGENERAL HOSPITAL ORIENTATION Revised: January 2013 EE Intl Hosp Ort
GENERAL HOSPITAL ORIENTATION 2013-2014 1 GOOD SAMARITAN HOSPITAL MANDATORY EDUCATION CLASSES ATTENDANCE OR SELF-LEARNING MODULE ACKNOWLEDGEMENT Organizational Mission, Vision, and Goals Cultural Diversity
More informationInformation in State statutes and regulations relevant to the National Background Check Program: Louisiana
Information in State statutes and regulations relevant to the National Background Check Program: Louisiana This document describes what was included as of January 2011 in Louisiana statutes and regulations
More informationMechanicsburg Area School District. Volunteer Handbook. 100 E. Elmwood Avenue 2 nd Floor
Mechanicsburg Area School District Volunteer Handbook Mechanicsburg Area SD 100 E. Elmwood Avenue 2 nd Floor Mechanicsburg, PA 17055 Phone: 717.691.4500 Fax: 717.691.3228 Website: www.mbgsd.org Mechanicsburg
More informationAppendix E Checklist for Campus Safety and Security Compliance
Checklist for Campus Safety and Security Compliance The Handbook for Campus Safety and Security Reporting 267 This page intentionally left blank. Checklist for the Various Components of Campus Safety and
More informationPolice may conduct these checks. The following is a summary of various methods used for background checks and the requirements for each.
Criminal Background Check and Security Check Policy for Nursing Facility Management in Louisiana Introduction All of our facilities are committed to the health, safety, and welfare of our residents. Part
More informationInformation in State statutes and regulations relevant to the National Background Check Program: Virginia
Information in State statutes and regulations relevant to the National Background Check Program: Virginia This document describes what was included as of February 2011 in Virginia statutes and regulations
More informationEllie welcomes you to Ridgeview Institute
Ellie welcomes you to Ridgeview Institute 3995 South Cobb Drive, Smyrna, Georgia 30080 Phone: 770-434-4567, 1-800-329-9775 Internet: www.ridgeviewinstitute.com Ridgeview Institute is a private, not-for-profit
More informationWelcome to Junior Volunteer Orientation 2012
Welcome to Junior Volunteer Orientation 2012 This computer based training (CBT) contains a lot of important information. Please review this information carefully. It is very important that you understand
More informationBACKGROUND CHECK PROGRAM
BACKGROUND CHECK PROGRAM Effective July 1, 2018 I. PURPOSE OF BACKGROUND CHECK The purpose of the Department of Recreation and Parks Background Check Program is to ensure that every individual who interacts
More informationNOTE: This is an 8-page document Read ALL!!!
NOTE: This is an 8-page document Read ALL!!! PRE-SERVICE TRAINEES BASIC TRAINING PROGRAM Act 120 - Municipal Police Officers' Education and Training Commission For admission to the HACC Central Pennsylvania
More informationCampus Crime & Security Report Harrisburg Campus
Campus Crime & Security Report Harrisburg Campus Harrisburg University of Science & Technology strives to offer a safe and secure campus. The Director of Compliance has the primary responsibility for supervising
More informationbring it with you to your scheduled interview (do not submit this with your application);
Dear Volunteer Applicant: Thank you for your interest in the Volunteer Services program at Carolinas HealthCare System Lincoln. Joining the dedicated team of adult and teen volunteers can be a richly rewarding
More informationYALE-NEW HAVEN HOSPITAL MEDICAL STAFF POLICY & PROCEDURE CONFLICT OF INTEREST
YALE-NEW HAVEN HOSPITAL MEDICAL STAFF POLICY & PROCEDURE CONFLICT OF INTEREST Definitions External financial interests can create conflicts when they provide an incentive to a Medical Staff member to affect
More informationCrime in Arkansas Section 9 National Incident - Based Crime Reporting System
Section 9 National Incident - Based Crime Reporting System 143 Overview In 1985, the FBI introduced the National Incident-Based Crime Reporting System (NIBRS) to improve the statistical reporting and analysis
More informationBON SECOURS DEPAUL MEDICAL CENTER
BON SECOURS DEPAUL MEDICAL CENTER 150 Kingsley Lane, Norfolk Virginia 23505 Main Number: 757-889-5000 Volunteer Office: 757-889-5340 VOLUNTEER SERVICES Orientation Agenda I. Welcome II. Objective TO BE
More informationViolence In The Workplace
Violence In The Workplace Preventing and Responding to Violence in The Medical Practice Workplace Presented by Tom Loughrey Economedix, LLC From The National Institute of Occupational Safety and Health
More informationUniform Employment Application for Nurse Aide Staff
Uniform Employment Application for Nurse Aide Staff This application form is required by Title 63 O.S. Section 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This
More informationImpact of Criminal Convictions on Registration of Medication Aides and Licensure of Massage Therapist in Virginia
Impact of Criminal Convictions on Registration of Medication Aides and Licensure of Massage Therapist in Virginia INTRODUCTION Certain criminal convictions may prevent registration of medication aides
More informationDirections for Submitting a Complete Application for the Precertification Nursing Assistant Training Course Fall 2018
Directions for Submitting a Complete Application for the Precertification Nursing Assistant Training Course Fall 2018 Application Acceptance: May 1 May 31, 2018 All applications are evaluated for the elements
More informationNorth Georgia Technical College Annual Security Report 2011
North Georgia Technical College Annual Security Report 2011 ANNUAL CRIME STATISTICS; NGTC- Clarkesville Main Campus Offense Type Year On-Campus Residential Facility Non-Campus Building / Property Public
More informationReturning Volunteer Application
Returning Volunteer Application Office Use Only Application Received Brenda LeBlanc, Volunteer Coordinator 978-683-4000 x2645 Brenda.leblanc@lawrencegeneral.org Welcome! Returning Volunteers, Before returning,
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: July 12, 2017 THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO
More informationFor detailed information regarding the programs and services, as well as information about the Department itself, please visit
UCPD Annual Report & Crime Statistics 2007 - U.C. Riverside Program Highlights PDF Version For 2007, the most significant program highlighted is the partnership of the Police Department, Computing and
More informationFor detailed information regarding the programs and services, as well as information about the Department itself, please visit
U.C. Riverside Program Highlights PDF Version For 2008, the most significant program highlighted is the partnership of the Police Department, Computing and Communication and Environmental Health & Safety
More informationBACKGROUND VERIFICATION INSTRUCTIONS
BACKGROUND VERIFICATION INSTRUCTIONS Policy 001-2014 NASAR policy requires background verifications for participation in certain positions and to comply with the National Child Protection Act. Due to your
More informationFootball & Cheerleading. Youth Sports Coaches Volunteer Application
Football & Cheerleading Youth Sports Coaches Volunteer Application YOUTH SPORTS VOLUNTEER JOB DESCRIPTION TITLE: DESCRIPTION: Volunteer Coach for Gainesville Parks and Recreation Agency. *Coach of male
More informationUCR CHECKLIST- UNVERIFIED DATA FOR REVIEW& VERIFICATION. Agency Name: Population: Year: N/ A. Crime Rate:
UCR CHECKLST- UNVERFED DATA FOR REVEW& VERFCATON FL58 Agency Name: 7 SA Population: Clearance Rate: 9. Crime Rate: Date Generated: 7/ 5/ 7 Arrest Data Provided LEOKA Data Comparative Prior Year Data Agency
More informationI. INTRODUCTION. 1. Los Angeles County Code Chapter The County Badge Ordinance (1960) 2. California Assembly Bill 1153 (March, 2004)
I. INTRODUCTION A. Purpose: To establish rules and regulations covering the authorization, issuance, use, possession, loss, theft, sale, manufacture, destruction and return of all official Fire Department
More informationCOUNTY OF SACRAMENTO Probation Department
COUNTY OF SACRAMENTO Probation Department 9750 BUSINESS PARK DRIVE, SUITE 220, SACRAMENTO, CALIFORNIA 95827 TELEPHONE (916) 875-0273 FAX (916) 875-0347 LEE SEALE CHIEF PROBATION OFFICER COUNTY PAROLE OFFICER
More informationUniform Employment Application for Nurse Aide Staff
This application form is required by Title 63 O.S. 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for
More informationREGISTERED OFFENDERS IN HEALTH CARE FACILITIES
REGISTERED OFFENDERS IN HEALTH CARE FACILITIES The 2005 Legislature enacted a number of provisions related to the admission of registered offenders to health care facilities. These provisions went into
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC SANTA BARBARA Annual 1. UC Santa Barbara FBI Part I Crime 2 2. UC Santa Barbara FBI Part II Crime 3 3. UC Santa Barbara Arrests - FBI Crime 4 4. UC Santa Barbara
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC SAN DIEGO Annual 1. UC San Diego FBI Part I Crime 2 2. UC San Diego FBI Part II Crime 3 3. UC San Diego Arrests - FBI Crime 4 4. UC San Diego Value of Stolen and
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC LOS ANGELES Annual 1. UC Los Angeles FBI Part I Crime 2 2. UC Los Angeles FBI Part II Crime 3 3. UC Los Angeles Arrests - FBI Crime 4 4. UC Los Angeles Value of
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC IRVINE Annual 1. UC Irvine FBI Part I Crime 2 2. UC Irvine FBI Part II Crime 3 3. UC Irvine Arrests - FBI Crime 4 4. UC Irvine Value of Stolen and Recovered Property
More informationDear PN Applicant. Sincerely, The PN Program Faculty North Arkansas College
Dear PN Applicant We are happy you are considering the Practical Nursing Program at North Arkansas College. The PN Program has been granted full approval by the Arkansas State Board of Nursing and traditionally
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. WHY ARE YOU GETTING
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC DAVIS Annual 1. UC Davis FBI Part I Crime. UC Davis FBI Part II Crime 3 3. UC Davis Arrests - FBI Crime. UC Davis Value of Stolen and Recovered Property 5 5. UC
More informationUC POLICE DEPARTMENT REPORTS DASHBOARD
UC POLICE DEPARTMENT REPORTS DASHBOARD UC BERKELEY Annual 1. UC Berkeley FBI Part I Crime 2 2. UC Berkeley FBI Part II Crime 3 3. UC Berkeley Arrests - FBI Crime 4 4. UC Berkeley Value of Stolen and Recovered
More informationIVROP JOB SHADOW PROGRAM ORIENTATION
IVROP JOB SHADOW PROGRAM ORIENTATION Hospital Incident Command System (HICS) Emergency Codes Hospital Emergency Incident Command System Emergency Codes HEICS Emergency Codes These codes are part of the
More informationMedical Assistant- CNA Bridge Program
Medical Assistant- CNA Bridge Program Name (Your name as it will appear on your name tag) This noncredit "bridge" course provides training for medical assistants to transition to Certified Nursing Assistant
More information2017 Annual Mandatory Education. Sarasota Memorial Health Care System
2017 Annual Mandatory Education Sarasota Memorial Health Care System Self-Study Module Questionnaire The goals of Annual Mandatory Education are to provide employees with information pertinent to their
More informationVolunteer Manual. West Jefferson Hills School District
Volunteer Manual West Jefferson Hills School District Thank you for taking time to share your gifts and talents with the students of the West Jefferson Hills School District. By volunteering, you join
More informationDepartment of Defense INSTRUCTION
Department of Defense INSTRUCTION NUMBER 5505.11 July 21, 2014 Incorporating Change 2, March 30, 2017 SUBJECT: Fingerprint Card and Final Disposition Report Submission Requirements References: See Enclosure
More informationGilmer Independent School District 500 So. Trinity Gilmer, Texas Phone: (903) FAX: (903)
Gilmer Independent School District 500 So. Trinity Gilmer, Texas 75644 Phone: (903) 841-7400 FAX: (903) 843-5279 Employment Application for Professional Personnel POSITION (S) FOR WHICH YOU ARE APPLYING:
More informationBy then end of this course the participant will be able to: 0 Identify the emergency codes and what extension to use to activate the system.
Agenda: By then end of this course the participant will be able to: 0 Identify the emergency codes and what extension to use to activate the system. 0 Explain the staff role in keeping RCHSD a safe place
More informationVolunteer Application
Volunteer Application Applicant Information First Name: Middle Initial: Last Name: Address: City: State: Zip: Home Phone: Cell Phone: Email: Occupation: Special Skills: Volunteer Preferences Have you previously
More informationAIC College of Design 2017 Annual Safety Report
2017 Annual Safety Report Jeanne Clery Disclosure of Campus Security & Campus SAVE Act Marion Allman, CEO Sean Mendell, President The Art Institute of Cincinnati d.b.a. AIC College of Design 1171 E. Kemper
More informationNOTICE OF PRIVACY PRACTICES
535 East 70th Street New York, NY 10021 (212) 606-1000 Specialists in Mobility NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
More informationPRACTICAL NURSING APPLICATION PROCEDURE AND DEADLINE:
1 APPLICATION PROCEDURE AND DEADLINE: Classes are admitted in August and January. Class size is limited, and all applicants are not accepted for participation. All applicants will have an equal opportunity
More informationLSU Health Sciences Center New Orleans Workplace Violence Prevention Plan
LSU Health Sciences Center New Orleans Workplace Violence Prevention Plan Effective January 1, 1998 Governor Mike J. Foster, Jr., of the State of Louisiana issued Executive Order MJF 97-15 effective March
More informationLCCW Annual Security Report
LCCW Annual Security Report Life Chiropractic College West Annual Security Report The Annual Security Report is provided to the staff, faculty and students of the college and, upon request, to prospective
More informationAPPLICATION FORM. 128 E. 8 th Street, 1338A Colegate Drive Cambridge, Oh Marietta, Ohio Name: Last First Middle.
Chris Keylor, Superintendent Megan Atkinson, Treasurer Date of Application: APPLICATION FORM 1. Please complete this application and return to Ohio Valley ESC: Cambridge Office Marietta Office 128 E. 8
More informationApplication for Administrative Position for
Application for Administrative Position for For information, please contact: David N. Branch, Muskingum Valley Educational Service Center Muskingum Valley ESC 205 N. Seventh St., Zanesville, OH 43701 Phone:
More informationFAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013
FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: May 31, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
More informationVOLUNTEER APPLICATION
Thank you for your interest in Estes Park Medical Center. The mission of the Estes Park Medical Center is to make a positive difference in the health and wellbeing of all we serve. VOLUNTEER APPLICATION
More informationBasic Nurse Assistant Program Fall 2016 If you are interested in becoming a CNA, this information will be helpful.
Basic Nurse Assistant Program Fall 2016 If you are interested in becoming a CNA, this information will be helpful. The CNA program has very strict attendance policies. Please note: ALL CLASS AND LAB TIME
More informationGLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER
100 Sulphur Springs Road Brunswick, GA 31520 Telephone: (912) 554-7600 Web Page Address: www.glynncountysheriff.org INSTRUCTIONS AND INFORMATION PLEASE READ CAREFULLY BEFORE BEGINNING 1. Please complete
More informationNEW EMPLOYEE ORIENTATION SAFTEY QUIZ EMPLOYEE ID#: DEPARTMENT: DATE:
NEW EMPLOYEE ORIENTATION SAFTEY QUIZ NAME: EMPLOYEE ID#: DEPARTMENT: DATE: Directions: Please read Annual Safety Training and complete Safety Quiz. Sign the acknowledgement form regarding Steward s Privacy
More informationArk. Admin. Code Alternatively cited as AR ADC Repealed
Ark. Admin. Code 016.22.1-100 016.22.1-100. Repealed Ark. Admin. Code 016.22.1-101 016.22.1-101. Related Laws and Requirements 1. The Child Care Facility Licensing Act Ark. Code Ann. 20-78-201-220, as
More informationService Provider. Partnership Application. (June August)
Service Provider Partnership Application (June August) City of New Orleans Mitchell J. Landrieu, Mayor Victor N. Richard, II NORDC CEO Revised October 2016 SUMMER CAMP PARTNERSHIP APPLICATION Thank you
More informationNursing Jurisprudence and Ethics: For School Nurses. Thank You to TSNO. Continuing Nursing Education 3/1/17
3/1/17 Nursing Jurisprudence and Ethics For School Nurses Adalia Del Bosque MS, RN Karen Schwind BN, RN, NCSN Texas School Nurse Organization Region 1 Conference 2017 School Nurses Impacting Our Children
More informationPractical Nursing Program Information and Application Packet
Practical Nursing Program Information and Application Packet The UACCB Practical Nursing Program is approved by the Arkansas State Board of Nursing, University Tower Bldg., 1123 South University, Suite
More informationBasic Nurse Assistant Program Fall 2017
Basic Nurse Assistant Program Fall 2017 Registration Requirements: 1. New Students New LLCC students may be required to attend a New Student Orientation session prior to registration. You may contact Registration
More informationNOTICE OF PRIVACY PRACTICES
Amended September 2013 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
More informationAPPLICATION FOR EMPLOYMENT CLARK COUNTY SHERIFF S OFFICE
APPLICATION FOR EMPLOYMENT CLARK COUNTY SHERIFF S OFFICE PO Box 566 / 221 West 9th Avenue Ashland, Kansas 67831 Office: 620-635-2802 Fax: 620-635-2148 www. clarkcountysheriffks.com Dear Public Safety Applicant:
More informationCatholic Charities Disabilities Services. In-Home Behavioral Support Services (2017)
Catholic Charities Disabilities Services In-Home Behavioral Support Services (2017) A Program funded through a Family Support Services Grant from OPWDD Submit Application and supporting documentation to:
More informationVOLUNTEER MANUAL PLEASE READ THIS MANUAL AND OBTAIN ALL REQUIREMENTS BEFORE RETURNING YOUR COMPLETED PACKET TO THE DISTRICT ADMINISTRATION OFFICE.
VOLUNTEER MANUAL Due to the requirements set by Pennsylvania State Law, ALL Susquehanna Township School District Volunteers must be registered with the Volunteer Program. This Volunteer Manual contains
More informationGUILFORD COUNTY SCHOOLS RFP # 5189 Request For Proposal to provide Nursing/Nursing Assistant Services (CNA)
GUILFORD COUNTY SCHOOLS RFP # 5189 Request For Proposal to provide Nursing/Nursing Assistant Services (CNA) Proposals are being solicited for Nursing Services (CNA) for students in the Guilford County
More informationVICTIMS SERVICES QUARTERLY REPORT FORM COMMUNITY BASED PROGRAMS. Table 1 - New Cases Referred to VSU and New Persons Assisted
VICTIMS SERVICES QUARTERLY REPORT FORM COMMUNITY BASED PROGRAMS Year: indicate the four digits of the year. Instructions for Completion April 1, 2010 Quarter: victim services information is collected on
More informationLPN to RN ADMISSION REQUIREMENTS
LPN to RN ADMISSION REQUIREMENTS Students must turn in a complete application packet in a plain manila envelope to a Nursing Program Advisor, Room 191-B, prior to the listed application deadlines. Incomplete
More informationNOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Respect for
More informationOrganizational Provider Credentialing Application
Prior to completing this credentialing application, please read and observe the following: INSTRUCTIONS This form should be typed (using a different font than the form) or legibly printed in black or blue
More informationCampus Safety and Security Policy and Fire Safety Report
PAGE 1 OF 28 INTRODUCTION: This document has been designed to inform all students and employees about the school s safety and security procedures and policies. The annual disclosure document is done each
More informationPATIENT SAFETY. Prevention of Error Physician and ADP Roles and Responsibilities
PATIENT SAFETY Prevention of Error Physician and ADP Roles and Responsibilities Patient Safety At Navicent Health is our goal to provide the safest possible environment for our patients. Providing a safe
More informationGUILFORD COUNTY SCHOOLS RFP # 5189 Request For Proposal to provide Nursing/Nursing Assistant Services (CNA)
GUILFORD COUNTY SCHOOLS RFP # 5189 Request For Proposal to provide Nursing/Nursing Assistant Services (CNA) Proposals are being solicited for Nursing Services (CNA) for students in the Guilford County
More informationVolunteers in Schools
REGULATION MONTGOMERY COUNTY PUBLIC SCHOOLS Related Entries: Responsible Offices: ABA, ABA-RB, ABC, ABC-RA, CNA, CNA-RA, COA-RB, EIB- RA, GDA-RB, IPD-RA, JHC, JHC-RA Chief Academic Officer Deputy Superintendent
More informationPHLEBOTOMY CERTIFICATE PROGRAM APPLICATION FOR 2018
1 NURSING AND HEALTH SCIENCES Admission Packet PHLEBOTOMY CERTIFICATE PROGRAM APPLICATION FOR 2018 FLORIDA GATEWAY COLLEGE For additional information and guidance, before you apply to one of the programs,
More informationEmployer Instructions for Use ODH Form 805 Uniform Employment Application for Nurse Aide Staff
Effective November 1, 2012 Employer Instructions for Use ODH Form 805 Uniform Employment Application for Nurse Aide Staff Purpose This form is to be used by employers as the only employment application
More informationDepartment of Juvenile Justice Guidance Document COMPLIANCE MANUAL 6VAC REGULATION GOVERNING JUVENILE SECURE DETENTION CENTERS
COMPLIANCE MANUAL 6VAC35-101 REGULATION GOVERNING JUVENILE SECURE DETENTION CENTERS This document shall serve as the compliance manual for the Regulation Governing Juvenile Secure Detention Centers 6VAC35-101)
More informationDeSoto County School of Practical Nursing
DeSoto County School of Practical Nursing 310 West Whidden Street, Arcadia, Florida 34266 (863) 993-1333 FAX: (863) 993-9181 Re: Practical Nursing Program 2018/2019 Dear Applicant, Thank you for your interest
More informationAmeriCorps Application Packet
AmeriCorps Application Packet Dear Friend, Fill out the application to the best of your ability. Must be 18 years or older with a High School Diploma or GED to apply. Must be a U.S. Citizen or National
More informationSign and return included forms. (Background Check Form, Authorization to Release Information Form, and Vehicle Use Agreement)
To: Employees with Conditional Offers of Employment Re: Background Checks All offers of employment or participation in any activity involving minors in a University sponsored program with The University
More informationCompliance Program And Code of Conduct. United Regional Health Care System
Compliance Program And Code of Conduct United Regional Health Care System TABLE OF CONTENTS Page MESSAGE FROM OUR PRESIDENT... 1 COMPLIANCE PROGRAM... 2 Program Structure...2 Management s Responsibilities
More informationBasic Nurse Assistant Program Spring 2018
Basic Nurse Assistant Program Spring 2018 The CNA program has very strict attendance policies. Please note: ALL CLASS AND LAB TIMES ARE REQUIRED BY THE ILLINOIS DEPARTMENT OF PUBLIC HEALTH. Attendance
More information