1. - Healthsource · PDF fileCompetency and Medication Test. Tests will be given prior to...

Essential File Documents

Below are the essential file documents that we need from you. Your file must be complete and in compliance with regulations and each item must remain current while you are working.

1. A HealthSource Global Staffing application and signed paperwork in the Essential Documents.

2. A Clinical Skills Checklist to coincide with your specialty(s).

3. Clear and current copies of all nursing licenses and we recommend American Heart Association BLS card. If you have ACLS, PALS, NRP, TNCC, or ENPC please provide us with copies of both front and back of each card. Also include any chemo and/fetal heart monitoring certificates. Certifications must be completed in a classroom environment. No on online certifications will be accepted.

4. A clear copy of your driver’s license or government-issued picture ID (Go to closest Motor Vehicle

Dept)

5. Signed and completed I-9 (Follow detailed instructions provided with your I-9 Form).

6. Clear copy of your social security card (a copy of your passport or birth certificate is acceptable).

7. A physical or signed physician’s statement declaring your ability to work as a nurse. This exam

must be within the past twelve months and on a HealthSource Global Staffing form.

8. A current negative TB screen within the last year. If the screen was positive, a current normal chest x-ray performed in the last two years

9. Proof of immunizations or positive titer results for mumps. Rubeola (measles), rubella and

varicella or MMR and Varicella shot. Immunizations must include the dates and initials of the healthcare provider. The titers can show the words “positive/immune,” or a number. If a number is given, a lab range indicating whether a number reflects a positive titer must be included. (A positive titer result must accompany history of disease).

10. Signed Hepatitis B documentation of one of the following: 1) declination 2) proof of titer, or 3)

vaccination series. If you have had the series, provide proof of immunization with dates and initials.

11. A signed Medical Release Form agreeing to a drug screening and /or background check if

required by hospital.

12. Competency and Medication Test. Tests will be given prior to start of assignment.

13. All Essential File Documents must remain current at all times. The hospital or company will not permit non-compliance. Most documents are valid for 1 year.

182 Howard Street #209 ▪ San Francisco, CA 94105 ▪ Toll Free (800) 458.8973 ▪ Fax (866) 878.8617 www.healthsourceglobal.com

1

300 Brannan Street Suite 508 ▪ San Francisco, CA 94107 ▪ Toll Free: (800) 458-8973 ▪ Fax: (866) 878-8617 www.healthsourceglobal.com

-

Employment Application Personal Information Date Last Name: _________________________________First Name: _________________________Middle: ______ (Name as it appears on you SS card) Street: _____________________________________________________________________________________ (Current/Permanent Mailing Address) District: _____________________________________City: _________________________________________ Province/State: ____________________________ Zip Code: ________________________________________ (Person to notify in case of Emergency): Phone #: _____________________Cell #: __________________Contact: _______________ #: ______________ Email Address: _____________________________________________Fax # ____________________________ Social Security Number: ______________________________ Date of Birth: __________________________

Type of Professional RN □ Other please specify □ ______________________________________

Are you currently working as a Nurse? Yes □ No □ If no, why? ___________________________________ What language(s) do you speak fluently? _____________________How did you hear about us? _____________ What is your area (s) of current nursing specialty? ___________________________How long? _____________ What other area (s) of specialty have you worked? ___________________________How long? _____________ Licensure: (Include clear photocopies of all licenses held.) State: ____ License # _____________ Exp. Date: _________ State: ____ License # _____________ Exp. Date: _________ State: ____ License # _____________ Exp. Date: _________ State: ____ License # _____________ Exp. Date: _________ Current Certifications: (Provide clear photocopies of all certification held)

□ BLS □ACLS □ PALS □ NRP □ TNCC □ CHEMO □ Other (s) ____________________ Exp Dates: _______ _______ _______ _______ _________ _________ Education and Training Education Name and Address of School Month/Year

Graduated Diplomas, Degrees received

College

Graduate School

Other School (if applicable)


-

Employment History (Please start with your current or most recent job. DO NOT LIST AGENCY NAMES.) Hospital/Employer _____________________________Unit / Dept. worked _____________________________ Street address _______________________________City _____________ Province ____________Zip ______ Dates of employed: From _________ To _________ Reason for leaving ____________________________ Position held _____________________________Unit Specialty _________________ Did you do charge? Y / N Responsibilities _____________________________________________________________________________ Immediate Supervisor __________________________Phone ____________________________________ Hospital/Employer _____________________________Unit / Dept. worked _____________________________ Street address _______________________________City _____________ Province ____________Zip ______ Dates of employed: From _________ To _________ Reason for leaving ____________________________ Position held _____________________________Unit Specialty _________________ Did you do charge? Y / N Responsibilities _____________________________________________________________________________ Immediate Supervisor __________________________Phone ____________________________________ Hospital/Employer _____________________________Unit / Dept. worked _____________________________ Street address _______________________________City _____________ Province ____________Zip ______ Dates of employed: From _________ To _________ Reason for leaving ____________________________ Position held _____________________________Unit Specialty _________________ Did you do charge? Y / N Responsibilities _____________________________________________________________________________ Immediate Supervisor __________________________Phone ____________________________________ Hospital/Employer _____________________________Unit / Dept. worked _____________________________ Street address _______________________________City _____________ Province ____________Zip ______ Dates of employed: From _________ To _________ Reason for leaving ____________________________ Position held _____________________________Unit Specialty _________________ Did you do charge? Y / N Responsibilities _____________________________________________________________________________ Immediate Supervisor __________________________Phone ____________________________________


-

Hospital/Employer _____________________________Unit / Dept. worked _____________________________ Street address _______________________________City _____________ Province ____________Zip ______ Dates of employed: From _________ To _________ Reason for leaving ____________________________ Position held _____________________________Unit Specialty _________________ Did you do charge? Y / N Responsibilities _____________________________________________________________________________ Immediate Supervisor __________________________Phone ____________________________________ We will use your current resume for all other job history information. Is there any medical condition (s) which may limit your ability to perform any function required of a nurse? Yes □ No □ Have you ever been convicted of a crime other than a minor traffic violation? Yes □ No □ Has your professional license or certification ever been investigated or suspended? Yes □ No □ Can you submit verification of your legal right to work in the USA? Yes □ No □ I attest that the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information my result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. Print Name ______________________________________________ Signature ___________________________________________ Date ______________________

Employee Confidentiality Agreement

As an employee of HealthSource Global Staffing, you have both a legal and ethical responsibility to protect the privacy of employees, client nurses and hospitals as well as all proprietary information of HealthSource Global Staffing. All information that you see or hear regarding nurses, staff, patients, directly or indirectly, is completely confidential and must not be discussed or released in any form, except when required in the performance of your duties. If you have access to employee information, you are expected to treat such information in the same confidential manner. Unauthorized disclosure of medical information is also criminally punishable as a misdemeanor. The mere public acknowledgement of HIV disease, psychiatric disorders, drug abuse or alcohol abuse may expose the company to both substantial fines and liability to the person. Any information provided to you by the nurses or hospitals is considered confidential and should not be shared with other except when required in the performance of your duties. I have read the above information and understand that any violation of this agreement is cause for immediate action. ________________________________________ ___________________________ Print Name Date ________________________________________ Signature

300 Brannan Street Suite 508 ▪ San Francisco, CA 94107 ▪ Toll Free (800) 458.8973 ▪ Fax (866) 878.8617 www.healthsourceglobal.com

2

Employee Authorization to Release Employee Information and Consent for Background Investigation and

Random Drug Screening

My signature below signifies my authorization for HealthSource Global Staffing to release any or all information contained within my employment file to any medical facility or entity with whom the company contacted to receive HealthSource Global Staffing and any regulatory or governmental agency upon that agency’s request. My signature further allows HealthSource Global Staffing to request any additional necessary medical information from my care provider(s) to complete HealthSource Global Staffing medical history for my employee file. I agree to submit to random alcohol and/or drug screens used for the purpose of determining my fitness for employment or continued employment, and I hereby authorize HealthSource Global Staffing to conduct background investigations of my activities, education and employment. I agree that HealthSource may make the decision to release any and all information at its discretion providing such release is made to authorized representatives of appropriate entities as described. I understand that in all other cases, my employment records will remain confidential and will only be released with my written authorization. My signature here indicates that I have read this Employee authorization to Release Employee Information and Consent for Background Investigation and Random Drug Screening in its entirety and understand its contents. Employee signature __________________________________ Date ______________ HealthSource _______________________________________ Date ______________


3

182 Howard Street #209▪ San Francisco, CA 94105 ▪ Toll Free: (800) 458.8973 (866) 661.0028 ▪ Fax (866) 878.8617

www.healthsourceglobal.com

OSHA STANDARDS AND COMPENTENCY ASSESSMENT

In compliance with JCAHO and OSHA requirements, I acknowledge that I have

Successfully completed the competency assessment as well as all of the following:

• Age Specific Job Requirements • Back Safety • Blood Borne Pathogens/Infectious Disease • Disinfection and Sterilization • Electrical Safety • Ergonomics for Healthcare Workers • Fire Safety • Handling of Hazardous Materials • Hand Washing • HIPAA Privacy Compliance • Personal Protective Equipment • Patient Bill of Rights • Patient Confidentiality • Radiation Safety • Tuberculosis • Violence in the Workplace • 2007 Patient Safety goals • Cultural diversity and sensitivity training

______________________________________________________________________ Print your Name Date Signature Health Source Representative

Employee Awareness Statement for California Penal codes

California Law requires all hospital employees to sign statements acknowledging that they are aware of their responsibilities with regard to section 11166 of the California Penal code and Section 15630 of the California Welfare and Institutions code, and to comply with the state obligations. Section 11166 (Child Abuse) of the Penal code requires any child care custodian, medical practitioner or employee of a child protective agency who has knowledge of or observes a child in his/her professional capacity or within the scope of his/her employment who he/she knows or reasonably suspects has been the victim of child abuse to report the suspected instance of child abuse to a child protective agency immediately or as soon as practically possible by telephone and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. Section 15630 (Elder Abuse) of the Welfare and Institutions code requires any elder of dependent adult care custodian, health practitioner, or employee of a county adult protective service agency or a local law enforcement agency who in his/her professional capacity or within the scope of his/her employment, either has observed and incident that reasonably appears to be physical abuse, has observed a physical injury where the nature of the injury, it’s location on the body or the repetition of injury, clearly indicates that physical abuse had occurred, or is told by an elder or dependent adult that he/she has experienced behavior constituting physical abuse, shall report the know or suspected instance of physical abuse either to the long-term care ombudsman coordinator or to a local law enforcement agency when the physical abuse is alleged to have occurred in a long-term care facility, or to their county adult protective services agency or to a local law enforcement agency when the physical abuse is alleged to have occurred anywhere else, immediately or as soon as possible, by telephone and to prepare and send a written report there of within 36 hours. Section 11166-1163 (Suspected Violent Injuries/Suspected Domestic Violence Injuries) of the Penal code requires reporting of any cases of patients with physical injuries caused by violent behavior to include domestic violence. Any health practitioner employed in a health facility, clinic, or physicians office who is in his/her professional capacity or within the scope of his/her employment, provides medical services for physical condition to a patient whom he/she knows or reasonably suspects is a person described as follows, shall immediately make a report of:

1. Any person suffering from any wound or other injury inflicted by his/her own act or inflicted by another where the injury Is by means of a firearm.

2. Any person suffering from any wound or other physical injury inflicted upon the person where the injury is the result of assaultive or abusive conduct.

This report shall be made to a local law enforcement agency as follow:

1. A report by telephone shall be made immediately or as soon as practically possible. 2. A written report shall be prepared and sent to a local law enforcement agency within two working days of receiving the

information regarding the person. I certify that I have read and understand this statement and will comply with my obligation under these laws. Furthermore, I understand That I may be fully prosecuted by the State under these Penal codes for failure to comply with the law. _______________________________________________________ ________________________________________________ Print Name Date _______________________________________________________ Signature ________________________________________________________ HealthSource Representative


5

Physician’s Statement Print Nurse Name: _________________________________________________________________________

Submit supporting documentation of immunization records and laboratory reports TYPE DATE RESULT TYPE DATE SIGNATURE

TB/PPD Test Hepatitis B Titer ___Immune ___Non-immune

Chest X-Ray (If TB test is positive)

Series Hepatitis B Vaccine – 1

MMR Hepatitis B Vaccine – 2 Rubella Titer Hepatitis B Vaccine – 3 Rubeola Titer Mumps Titer TYPE DATE RESULT Varicella Titer or Varivax

Tetanus (History of chicken pox is not acceptable unless w/ pos. titer)

I have examined and obtained a current history on the individual named above; and to the best of my knowledge, he/she is in good physical and mental health, is free of any communicable diseases, has no physical limitations, and is able to function in his/her professional discipline and specialty on a full time basis at full capacity. Physician Signature _______________________________________________ Date ___________________________ Print Name ______________________________ License Number ___________________________________

HealthSource Global Staffing Employee to complete the following information if the statement applies:

↓ Hepatitis B Vaccination

OSHA requires all healthcare workers to be offered the Hepatitis B Vaccination by their employer.

□I understand the OSHA guidelines and DECLINE the Hepatitis B Vaccination. Signature _____________________________________ Date ____________________________________________

□I understand the OSHA guidelines and DECLINE because I have completed the Hepatitis B Vaccination. Signature _____________________________________ Date ____________________________________________

□ I understand the OSHA guidelines and need # ____ or boosters in the series. I will make arrangements to complete the series or booster, or I will make arrangements with HealthSource Global Staffing to receive this dose of the vaccine series. I will provide documentation of the series/booster to HealthSource Global Staffing and provide appropriate updates. Signature _____________________________________ Date _____________________________________________


6

Employment Reference

Please give two copies of this form to your healthcare references to complete. Then return them to HealthSource Global Staffing

I hereby authorize my past and present employer to provide information to HealthSource Global Staffing about my job performance while employed at the named Hospital/Facility

Applicant name: ________________________________SS# ________________________________ (Please print) Applicant Signature: __________________________________________________________________________

Name of Hospital/Facility: ___________________________________________________________________________

Address: ______________________________________________________________________________

Name of Supervisor: _______________________________ __________________________ (Manager, Charge Nurse or higher) Please Print Title Signature: ___________________________________________________________________________________

Performance Evaluation

Above Average Average Below Average Accurate and thorough documentation Adaptability to patient assignment Attendance and punctuality Enthusiasm toward job Communication skills Clinical skills Problem solving skills Professional appearance Productivity Professionalism Quality of work Cooperation Leadership ability Dates of Employment: From __________________To: _________________________________________ Specialty / Unit worked _______________________ ____________________________________________ Reason for Leaving: □Terminated □ Lay-Off □ Resigned □ Temporary Employee Would you hire this healthcare professional again? □ Yes □ No


7

Employment Reference

Please give two copies of this form to your healthcare references to complete. Then return them to

HealthSource Global Staffing I hereby authorize my past and present employer to provide information to HealthSource Global Staffing about my job performance while employed at the named Hospital/Facility

Applicant name: ________________________________SS# ________________________________ (Please print) Applicant Signature: __________________________________________________________________________

Name of Hospital/Facility: ___________________________________________________________________________

Address: ______________________________________________________________________________

Name of Supervisor: _______________________________ __________________________ (Manager, Charge Nurse or higher) Please Print Title Signature: ___________________________________________________________________________________

Performance Evaluation

Above Average Average Below Average Accurate and thorough documentation Adaptability to patient assignment Attendance and punctuality Enthusiasm toward job Communication skills Clinical skills Problem solving skills Professional appearance Productivity Professionalism Quality of work Cooperation Leadership ability Dates of Employment: From __________________To: _________________________________________ Specialty / Unit worked _______________________ ____________________________________________ Reason for Leaving: □Terminated □ Lay-Off □ Resigned □ Temporary Employee Would you hire this healthcare professional again? □ Yes □ No


8

EVALUATIONS FOR AGE SPECIFIC PERFORMANCE EXPECTATIONS

Check Yes or No in the appropriate spaces below to indicate your ability to demonstrate supportive behaviors necessary for age specific care by observation, documentation, chart review and in-service education.

NEONATE PEDIATRIC ADOLESCENT YOUNG ADULT

ADULT GERIATRIC

Knowledge of normal growth & development - Involves parent/guardian in care/teaching

Yes No

Yes No

Yes

No

Yes

No

Yes No

Yes

No

Ability to assess age-specific data

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Communication skills necessary to interpret age

specific responses to treatment

Yes No

Yes No

Yes No

Yes

No

Yes No

Yes

No

Ability to involve family or

significant other in decision

making related to plan of care

Yes No

Yes No

Yes

No

Yes

No

Yes No

Yes

No

Allows patient to maintain control

and involved decision making

whenever possible

Yes No

Yes No

Yes

No

Yes

No

Yes No

Yes

No

I hereby certify that the information provided above is an accurate and true representation of my skills and abilities relative to provide care to the age group cited above. Please Print Name:

Date:

Signature:


9



BLOOD BORNE PATHOGENS INSERVICE

The purpose of this in-service is to ensure the safety of both the patient and the medical service personnel in the workplace. The in-service will include the following:

• Exposure to Blood Borne Pathogens • Prevention of Needle Stick Injuries • Needle Capping • Universal Precautions • Who is at Risk • Appraising the Risk • Personal Protection • Disposal of Biohazards • New Laws and Federal Acts • New Technologies

This in-service is provided to all HealthSource Global Staffing healthcare workers and consists of a “Safety Trainer Video” and verbal presentation. I understand and agree to comply with all safety standards set forth by my employer, HealthSource Global Staffing. I certify by my signature below, that I have been provided with the HealthSource Global Staffing Blood Borne Pathogens In-service. ________________________________________________ ______________________ Print Name Date of In-Service ________________________________________________ Signature ________________________________________________ In-service Conducted by HealthSource Global Staffing Representative



HIPAA

This notice describes how health information about you may be used and disclosed. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I authorize HealthSource Global Staffing the use and disclosure of my health information. I understand that this will be used by HealthSource Global Staffing and its clients to evaluate my qualifications for employment opportunities as it relates to the healthcare field. This information may also be used for workers compensation and similar programs, and/or when necessary to reduce or prevent a serious threat to your health and safety, or health and safety of others. We will only make disclosures to a person or organization able to help prevent the threat. I further understand that if a person that receives this information is not a healthcare provider, the information disclosed may be re-disclosed and no longer protected by regulations. I understand that I may revoke this authorization at any time by sending a written request to HealthSource Global Staffing, except to the degree that action has been taken in reliance on upon this authorization. This authorization will expire one year from the dated signature below. _____________________________________ ______________________ Signature Date

Form W-4 (2007) Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Because your tax situationmay change, you may want to refigure yourwithholding each year.

Head of household. Generally, you may claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals.

Exemption from withholding. If you areexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Yourexemption for 2007 expires February 16, 2008.See Pub. 505, Tax Withholding and EstimatedTax.

Check your withholding. After your Form W-4takes effect, use Pub. 919 to see how thedollar amount you are having withheldcompares to your projected total tax for 2007.See Pub. 919, especially if your earningsexceed $130,000 (Single) or $180,000(Married).

Basic instructions. If you are not exempt,complete the Personal AllowancesWorksheet below. The worksheets on page 2adjust your withholding allowances based on

Two earners/Multiple jobs. If you have aworking spouse or more than one job, figurethe total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances areclaimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others.

Personal Allowances Worksheet (Keep for your records.) Enter “1” for yourself if no one else can claim you as a dependent

A

A ● You are single and have only one job; or

Enter “1” if:

B

● You are married, have only one job, and your spouse does not work; or

B ● Your wages from a second job or your spouse’s wages (or the total of both) are $1,000 or less.

$ % Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse ormore than one job. (Entering “-0-” may help you avoid having too little tax withheld.)

C C

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return

D

D E

E F

F

Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ©

H

H ● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

and Adjustments Worksheet on page 2.

For accuracy,complete allworksheetsthat apply.

● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobsexceed $40,000 ($25,000 if married) see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

$ Cut here and give Form W-4 to your employer. Keep the top part for your records.

OMB No. 1545-0074 Employee’s Withholding Allowance Certificate

W-4

Form Department of the TreasuryInternal Revenue Service

© Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.

1

Last name

2

Your social security number

Home address (number and street or rural route)

Married

Single

3

Married, but withhold at higher Single rate.

City or town, state, and ZIP code

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

5

5

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) $ 6

6

Additional amount, if any, you want withheld from each paycheck 7

I claim exemption from withholding for 2007, and I certify that I meet both of the following conditions for exemption.

● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and ● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

7

If you meet both conditions, write “Exempt” here ©

8

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete. Employee’s signature(Form is not validunless you sign it.) ©

Date ©

9

Employer identification number (EIN)

Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

Office code (optional)

10

Enter “1” if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit

4

If your last name differs from that shown on your social security card,check here. You must call 1-800-772-1213 for a replacement card. ©

Cat. No. 10220Q

Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)

Note. You cannot claim exemption fromwithholding if (a) your income exceeds $850and includes more than $300 of unearnedincome (for example, interest and dividends)and (b) another person can claim you as adependent on their tax return. Nonwage income. If you have a large amount

of nonwage income, such as interest ordividends, consider making estimated taxpayments using Form 1040-ES, Estimated Tax

G

Child Tax Credit (including additional child tax credit). See Pub 972, Child Tax Credit, for more information.

G

● If your total income will be between $57,000 and $84,000 ($85,000 and $119,000 if married), enter “1” for each eligible child plus “1” additional if you have 4 or more eligible children.

● If your total income will be less than $57,000 ($85,000 if married), enter “2” for each eligible child.

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using thePersonal Allowances Worksheet below. SeePub. 919, How Do I Adjust My TaxWithholding, for information on convertingyour other credits into withholding allowances.

Nonresident alien. If you are a nonresidentalien, see the Instructions for Form 8233before completing this Form W-4.

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Form W-4 (2007)

2007

itemized deductions, certain credits,adjustments to income, or two-earner/multiplejob situations. Complete all worksheets thatapply. However, you may claim fewer (or zero)allowances.

for Individuals. Otherwise, you may oweadditional tax. If you have pension or annuityincome, see Pub. 919 to find out if you shouldadjust your withholding on Form W-4 or W-4P.

OMB No. 1115-0136

INSTRUCTIONS

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in theU.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination.

EMPLOYERS MUST RETAIN COMPLETED FORM I-9

Section 1 - Employee. If an employee is rehired within three (3) years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B and:

All employees, citizens andnoncitizens, hired after November 6, 1986, must complete Section 1 of this form at the time of hire, which is the actual beginning of employment. The employer is responsible for ensuring that Section 1 is timely and properly completed.

examine any document that reflects that the employee is authorized to work in the U.S. (see List A or C),

-

Preparer/Translator Certification. The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his/her own. However, the employee must still sign Section 1.

record the document title, document number and expiration date (if any) in Block C, and complete the signature block.

-

-Photocopying and Retaining Form I-9. A blank I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed I-9s for three (3) years after the date of hire or one (1) year after the date employment ends, whichever is later.

Section 2 - Employer. For the purpose of completing this

For more detailed information, you may refer to the INS Handbook for Employers, (Form M-274). You may obtain the handbook at your local INS office.

Employers must complete Section 2 by examining evidence of identity and employment eligibility within three (3) business days of the date employment begins. If employees are authorized to work, but are unable to present the required document(s) within three business days, they must present a receipt for the application of the document(s) within three business days and the actual document(s) within ninety (90) days. However, if employers hire individuals for a duration of less than three business days, Section 2 must be completed at the time employment begins. Employers must record: 1) document title; 2) issuing authority; 3) document number, 4) expiration date, if any; and 5) the date employment begins. Employers must sign and date the certification. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. These photocopies may only be used for the verification process and must be retained with the I-9. However, employers are still responsible for completing the I-9.

Privacy Act Notice. The authority for collecting thisinformation is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by officials of the U.S. Immigration and Naturalization Service, the Department of Labor and the Office of Special Counsel for Immigration Related Unfair Employment Practices.Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

Section 3 - Updating and Reverification. Employers must complete Section 3 when updating and/or reverifying the I-9. Employers must reverify employment eligibility of their employees on or before the expiration date recorded in Section 1. Employers CANNOT specify which document(s) they will accept from an employee.

Reporting Burden. We try to create forms and instructions that are accurate, can be easily understood and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, 5 minutes; 2) completing the form, 5 minutes; and 3) assembling and filing (recordkeeping) the form, 5 minutes, for an average of 15 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536. OMB No. 1115-0136.

If an employee's name has changed at the time this form is being updated/ reverified, complete Block A.

If an employee is rehired within three (3) years of the date this form was originally completed and the employee is still eligible to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

Form I-9 (Rev. 11-21-91)N

PLEASE DO NOT MAIL COMPLETED FORM I-9 TO INS

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

form, the term "employer" includes those recruiters and referrers for a fee who are agricultural associations, agricultural employers or farm labor contractors.

Employment Eligibility VerificationU.S. Department of JusticeImmigration and Naturalization Service

A citizen or national of the United States

Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.

Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. #

(month/day/year)

Date of Birth (month/day/year)

StateCity Zip Code Social Security #

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named

Address (Street Name and Number, City, State, Zip Code)

and that to the best of my knowledge the employee

I attest, under penalty of perjury, that I am (check one of the following): I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

A Lawful Permanent Resident (Alien # AAn alien authorized to work until / /

(Alien # or Admission #)

is eligible to work in the United States. (State employment agencies may omit the date the employee began

Employee's Signature Date (month/day/year)

Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a personother than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

/

Print NamePreparer's/Translator's Signature

/

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A ORexamine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s)

ANDList B List CORList A

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

//

Print Name TitleSignature of Employer or Authorized Representative

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)Business or Organization Name

Section 3. Updating and Reverification. To be completed and signed by employer.

B. Date of rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employmenteligibility.

Document #: Expiration Date (if any):Document Title:

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year)Signature of Employer or Authorized Representative

Form I-9 (Rev. 11-21-91)N Page 2

Employment Eligibility Verification

employee began employment on

employment.)

OMB No. 1115-0136U.S. Department of JusticeImmigration and Naturalization Service

Expiration Date (if any): / /

/ / / /

employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the

/ /

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

Documents that Establish Documents that Establish

OR Identity AND

(INS Form N-560 or N-561) 2. Certificate of U.S. Citizenship

Identity and Employment Eligibility

7. Unexpired employment

1. Driver's license or ID card 1. U.S. social security card issued

9. Driver's license issued by a Canadian government authority

1. U.S. Passport (unexpired or

I-688A)

issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, sex, height, eye color and address

by the Social Security Administration (other than a card stating it is not valid for employment)

Card (INS Form I-688)

expired)

photograph

Form I-327)

Document (INS Form I-571)

Employment Eligibility

(INS Form N-550 or N-570)

2. Certification of Birth Abroad3. Certificate of Naturalization 2. ID card issued by federal, state issued by the Department of

State (Form FS-545 or Form DS-1350)

or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, sex, height, eye color and address

4. Unexpired foreign passport,with I-551 stamp or attached INS Form I-94 indicating unexpired employment authorization

3. Original or certified copy of abirth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal

3. School ID card with a

5. Alien Registration Receipt Card with photograph (INS Form I-151 or I-551)

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card 4. Native American tribal document6. Unexpired Temporary

7. U.S. Coast Guard Merchant Mariner Card

5. U.S. Citizen ID Card (INS Form7. Unexpired Employment

I-197)8. Native American tribal documentAuthorization Card (INS Form

6. ID Card for use of Resident8. Unexpired Reentry Permit (INS Citizen in the United States

(INS Form I-179)are unable to present a document listed above:

For persons under age 18 who

9. Unexpired Refugee Travel

authorization document issued by the INS (other then those listed under List A)

10. School record or report card10. Unexpired EmploymentAuthorization Document issued by the INS which contains a photograph (INS Form I-688B)

11. Clinic, doctor or hospital record

12. Day-care or nursery schoolrecord

Form I-9 (Rev. 11-21-91)N Page 3

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

Documents that Establish Both

COMPETENCY TEST

Name: _______________________ Date: ___________ TRUE FALSE

1 Your patient is a victim of domestic violence. Your first priority is to remove the patient from immediate danger.

2 A parent consistently non-compliant with a child's medication plan is considered to be neglecting the child.

3 Elderly abuse only occurs in under privileged families.4 It is considered abuse when a parent spanks a child on their bottom one

time and no marks are remaining.

5 Infants experience stranger anxiety between 6-9 months.6 Adolescents are seldom influenced by peer groups.7 With a confused elderly patient, it is not necessary to introduce yourself

repeatedly because they likely will not remember you.

8 Cultural Diversity includes responding respectfully and effectively to people of all cultures, classes, ethnic backgrounds, and beliefs / practices in providing healthcare.

9 Cultural Values influence decision making.10 Care-providers should assume all patients make their own decisions, even

if patient is female from a male dominated culture.

11 Next of kin can receive information on a deceased patient. Only the person listed in an Advance Directive can receive patient information.

12 A DNR request does not require obtaining a Doctor's order.

13 Patient abandonment is not an ethical or legal issue.14 Patients have a right to receive considerate and respectful care in a safe

setting regardless of age, gender, race, national origin, religion, sexual orientation, or gender.

15 Your patient has active TB, and is on Droplet Precautions. You should wear an approved mask within 30 feet of patient.

16 Hand washing is essential in disease prevention.17 Blood borne pathogens can be transmitted via skin rash or burn.18 You should report your status to your supervisor after you have been

febrile for 48 hours and have consulted a Doctor.19 Artificial nails 1/4" beyond finger tips are typically acceptable.

20 Proper ergonomics include assessment, lifting with your legs, and keeping objects close to you.

21 It is acceptable to recap needles to prevent medication leaking.

22 Narcotic administration does not require double checking.23 Fifty percent of accidental poisonings occur in the home.24 cc, QD, & QID are approved abbreviations.

Ethics- Patient Rights

Infection Control

Injuries

Medication Safety

Abuse Neglect

Age Related

Cultural Diversity

End of Life Care

HSG Competency110707-lkp

189 Howard Street #209 ▪ San Francisco, CA 94105 (800)-458-8973 ▪ Fax (866) 878-8617 ▪ www.healthsourceglobal.com

1

COMPETENCY TESTPain Management TRUE FALSE25 Pain should be measured according to the hospital approved tool.26 Pain is assessed one time daily only.

27 Surgical site verification requires verifying visually and verbally patients name, medical record number, ID bracelet, procedure, and surgical site should be marked.

28 If a sentinel event occurs on a weekend, you must report event the following business day.

29 Patients with communicable diseases do not have rights when it comes to confidentiality.

30 Critical lab results must be reported promptly.31 All procedures require a minimum of 2 patient identifiers.32 Hand off report is for weekend or holiday communication only.33 Verbal orders should be written down & read back to physician to assure

orders are clearly understood & documented.

34 Doctor ordered the least restrictive restraints for a confused patient with a feeding tube. The best restraint choice is a vest.

35 Restraint use always increases patients safety.36 Restraint orders must be renewed every 24 hours, must be least

restrictive method when clinically justified, and alternative attempts have been attempted and documented.

37 One can be exposed to hazardous materials thru broken skin.38 Monitor your exposure by wearing an appropriate badge or other

monitoring device.39 If exposed to chemicals, or hazardous materials, report to your supervisor

only after you become symptomatic.40 A multipurpose fire extinguisher may be used on any fire type.41 PASS (Pull, Aim, Squeeze, Sweep) is fire extinguishing procedure.42 It is ok to block or wedge open fire exits for short times.43 As temporary staff it is not important to participate in drills.44 Paper masks protect against aerosolized hazardous drugs.45 Using a "cheater" to convert 3-prong to 2-prong plug is acceptable.

46 Sexual Harassment is a form of discrimination.47 Making reasonable demands, and looking for help are signs of aggressive

behavior.48 Aggressive behavior may include: pacing nervously, restless, anxious,

throwing objects, hitting the wall. 49 Workplace violence includes physical assault, threatening behavior,

intimidation, or verbal abuse.50 As temporary staff I am not responsible to report violence.

I attest I am the person taking this Competency Test:

Signature:______________________________ Date:____________

Safety

Workplace Safety

Restraints

Patient Safety - Risk Management



2

MEDICATION TEST

Name: Date: 1 ____ In measuring fluids, 1 cubic centimeter is equal to 1 milliliter?

a TRUEb FALSE

2 ____

a Becoming sleepyb Respiratory depression c Becoming disoriented slightlyd Dry mouth

3 ____

a 0.15 ml.b 1.15 ml.c 1.5 ml.d 0.5 ml.

4 ____

a 80 ml/hrb 48 ml/hrc 16 ml/hrd 24 ml/hr

5 ____

a 22 gtts/minb 18 gtts/minc 12 gtts/mind 24 gtts/min

6 ____

a 188 ml/hrb 150 ml/hrc 135 ml/hrd 125 ml/hr

7 ____

a 1.75 mlb 2 mlc 4 mld 8 ml

1 of 3

The orders read to administer Gentamycin 1 gram in 125 ml D5W IV over 60 minutes. What should be the pump setting for this solution?

Cephalexin (Keflex) 200mg has been ordered for your patient. This medication(syrup)is supplied as 125 mg per 5ml. How many ml should the patient receive?

Your patient is receiving IV Morphine PRN, a serious side effect requiring monitoring after IV administration includes Jane suffering from:

Regular Insulin is labeled “100 U per 1ml.” How much insulin should be administered for a 15 Unit dose order?

Your patient is receiving Oxytocin (Pitocin) 16mu /hour to induce Labor. The bag of LR contains 20 units Oxytocin per 1000cc. How many ml / hr should the pump infuse?

Dr Dunn ordered one unit of PRBC's to be administered over 3 hours. The bag reads 220ml PRBC. Considering the drip factor for the blood tubing is 10 gtts/ml, what drip rate should be set to deliver PRBC safely?



MEDICATION TEST

Name:

8 ____

a Label the medication and place it in the narcotic box to administer laterb Discard the medication verified by a witness and document as suchc

9 ____

a Vitamin Kb Protamine Sulfatec Calcium Carbonated None of the above

10 ____

a 50 ml / hr 150 gtts / minb 75 ml / hr 125 gtts / minc 50 ml / hr 125 gtts / mind 20 ml / hr 150 gtts / min

Calculate the drip rate for the following IV orders. Place your answer in left blank space.Drip factor Amount fluid Infusion Rate Answers Choices

11 60 gtts. / ml 1000 ml 8 hours a. 13 gtts/min12 60 gtts. / ml 750 ml 7 hours b. 30 gtts/min13 15 gtts. / ml 600 ml 5 hours c. 125 gtts/min14 15 gtts. / ml 250 ml 2 hours d. 14 gtts/min15 10 gtts. / ml 825 ml 11 hours e. 31 gtts/min16 10 gtts. / ml 675 ml 8 hours f. 107 gtts/min

17 ____

a on timeb aheadc behindd none of the above

18 ____

a on timeb aheadc behindd none of the above 2 of 3

20,000 units of Heparin are added to 500ml of NS. Regulate the IV to deliver 2000 units of heparin per hour. The drip factor = 15gtts/ml. How many ml/hr should be administered? How many gtts/min?

When administering Warfarin Sodium (Coumadin), which of the following medications should be on hand to counteract possible side effects?

500 ml Lactate Ringers is ordered to infuse over 6 hours. The IV was hung at 10am. 300ml is remaining in the bag at noon. The IV is:

1000 ml 0.45% NaCl is to infuse over 8 hours. The IV was hung at 8pm. At midnight, the bag has 500ml. The IV is:

Send the medication to the pharmacy & cross the name off the narcotic sheet

You have prepared a requested narcotic for your patient, then your patient refuses the medication. Which measure is appropriate for you to take?



MEDICATION TEST

19 ____ All pediatric patients IV's should be regulated by infusion pumps.a TRUEb FALSE

20 ____

a Instruct patient it is important to drink plenty of fluids with this medicationb Instruct patient it is important to avoid salt with this medicationc Check heart rate, if above 60 bpm, administering medication is safed This is the correct dose, administer medication

21 ____

a Check patients blood pressureb Administer medication and document pulse ratec Compare patients radial pulse to their apical pulsed Administer medication and notify physician if pulse decreases

22 ____a Correct medication and doseb Correct time and routec Correct patientd All of the above

23 ____

a 1200b 1900c 2400d 2200

24 ____a 4.5 kgb 2.5 kgc 0.45 kgd 1.25 kg

25 ____a When obtaining medication and checking expiration dateb Prior to viewing, preparing, drawing concentration of medication to administerc Prior to returning medication or discardingd All of the above

I attest I am the person taking this Competency Test:

Signature:______________________________ Date:____________3 of 3

One pound is equal to:

When should you check medication order and labels?

Your Patient is to receive 25mg Lanoxin (Digoxin.) Which action is essential prior to administering this medication?

Lanoxin has been ordered for your patient. Prior to administering, you assess the radial pulse is 52. Which action is appropriate?

Basic patient rights of medication administration include:

500ml of D5W is ordered to infuse at 83 ml/hr. The fluid was started at 1300. You should anticipate it to be completed at what time?



Date post:	18-Mar-2018
Category:	Documents
Upload:	ngocong
View:	218 times
Download:	1 times