ACHC New Employee Packet 1
Avenal Community Health Center
Aria Community Health Center New Employee Package
Name: _____________________________________
Position: _____________________________________
Start Date: _____________________________________
Check list:
1. _____ New Employee Data Record
2. _____ W-4 _____(I-9) Fillable pdf form available
3. INS FORM ID #1
_____ ID #1 ____________________
_____ ID #2 ____________________
4. Current License and Certification
_____ Profession ________________
_____ CPR
_____ ALS/BLS/ ________________
_____________________________________________
_____________________________________________
5. Health Examination Scheduled Date of Exam __________________
_____ Medical History (Employee Physical Form)
_____ Hepatitis B series, T.B., and Influenza (Vaccine Form)
_____ Please make copies of these 2 forms & give them to the Director of Operations
6. Position Documents Reviewed and Signed
_____ Job Description
_____ Evaluation Form
_____ Abuse Reporting
_____ Confidentiality Policy & Statement (HIPPA)
_____ 10 Step Quick Reference HIPAA Guide (HIPPA)
_____ Employee HIPAA Compliance Signature Form (HIPPA)
_____ Disaster Plan (Safety)
_____ HCSI Inc, (HIPPA, OSHA) Training Sign On
_____ Chain of Infection and Hand Washing Techniques (Infection Control)
_____ Blood Borne Pathogens and Flow chart of “How to Report Exposure”
_____ Policies & Procedures
_____ Employee Manual (Need signed acknowledgement page)
ACHC New Employee Packet 2
_____ Policy on Gossip, Rumors and Innuendo
7. Applications
_____ Health Plan
_____ Dental Plan
8. _____ Job Training (Two week process)
9. Other
_____ Badge
_____ Uniforms (Reimbursement Benefit)
_____ Keys ______________________________ Green Cup _____ Date: ___________
10. _____ Schedule
_____ Probationary Evaluation Date ____________________
_____ Health & Dental Start Date ____________________
_____ Vacation Start Date ____________________
11. _____ Agreed upon salary
ACHC New Employee Packet 3
Employee Data Record CONFIDENTIAL To Be Filed in Separate Medical File
Name Social Security # - -
Last First Middle
Please Complete this New Employee Data Record. It will supply us information needed for our payroll and benefits programs.
Present Address City State Zip Phone( )
Previous Address City State Zip Phone( )
How long at present address? How long at previous address?
In Case of Emergency Notify: (Please Print) 1. Name Phone (Day): ( )
Address Phone (Night): ( )
City State Zip
2. Name Phone (Day): ( )
Address Phone (Night): ( )
City State Zip
Personal Data
Date of Birth / / Sex: □ Male □ Female
Have you ever been employed here before? □ Yes □ No If yes, give dates: From / / To / /
List any friends or relatives working for us
Have you ever been bonded? □ Yes □ No
If yes Please Explain
Voluntary Information
Marital Status □ Single □ Married □ Separated □ Divorced □ Widowed
Name of Spouse Number of Dependents including yourself
Dependent Children:
Name Sex Age Name Sex Age
1. 3.
2. 4.
Physical
Are you requesting reasonable accommodation to assist you to perform the essential functions of the job? □ Yes □ No
If yes, what reasonable accommodation do you believe will assist you in performing the essential functions of the job?
ACHC New Employee Packet 4
Military
Were you in the U.S. Armed Forces? □ Yes □ No If yes, which branch?
Rank at time of discharge?
List duties and special training
Your Reserve Status? Your Draft Status?
Do you have a military obligation that would affect your work schedule? □ Yes □ No
General
List any foreign language(s) you know and check the boxes that describe your ability.
Speak Some Speak Fluently Read Write
□ □ □ □
□ □ □ □
□ □ □ □
List any professional, trade, business or civic associations and any offices held. (Exclude memberships which would reveal sex, race,
religion, national origin, age, color, disability or other protected status.)
Organization Offices Held
List special accomplishments, publications, awards and licenses, (Exclude information which would reveal sex, race, religion, national
origin, age, color, disability or other protected status.)
List hobbies and interests
Educational and Work Experience Educational: List your last three (3) schools attended, starting with the most recent.
Name and Location Years Completed Did you Graduate? Course of Study
Major Degree
Work Experience: List your last three (3) employers, starting with the most recent.
Company Name Address Phone Supervisor Pay Rate
( ) $_____.__ per __
( ) $_____.__ per __
( ) $_____.__ per __
Signed ____________________________________________________________ Date ___________________
ACHC New Employee Packet 5
Avenal Community
Health Center 1000 Skyline Boulevard ● Avenal, CA 93204-0700
Last Name First Name Date
Date of Birth mm/dd/yy Sex Phone
Employee Physical Allergies: ________________________________________
Reason for Visit: Current Medications Dose/Freq
Follow-up visit:
Vital Signs: HT- WT- BP- / TEMP- P- R- LMP-
Sp02%
History:
Physical: General Appearance
+ - Acute Distress
+ - HEENT
+ - Chest
+ - Heart
+ - Abdomen
+ - Extremities
+ - Neuro
+ - Skin
+ - Ortho
Assessment Dx. 1 Dx. 3
Plan: Dx. 2 Dx. 4
Follow-up Lab X-ray Other Medication # Inst.’s
Days
Weeks
Months
Has F/U
Instructions / Referrals
1
2
3
4
5
PA MD
BMI_____
_______%
ACHC New Employee Packet 6
Avenal Community Health Center
1000 Skyline Blvd., P.O. Box 700
Avenal, CA 93204-0700
(559) 386-4500
Employee Name _____________________________________ Hire Date _____________________________
VACCINE FORM
Hepatitis B Series
Received (Dates) 1. 2. 3.
Declined (Signature & Dates)
Titer (Date, if indicated)
Tuberculosis
Test Date Read Date Titer or X-ray Results Comments
T / X + -
T / X + -
T / X + -
T / X + -
T / X + -
T / X + -
T / X + -
T / X + -
T / X + -
Influenza
Date Received Injection or Mist Declined (Date & Signature)
I / M
I / M
I / M
I / M
I / M
ACHC New Employee Packet 7
Example of Annual Job Performance Review Form (2 pgs)
ACHC New Employee Packet 8
ACHC New Employee Packet 9
Child Abuse Reporting Responsibilities With concern or the total well being of each patient, all employees of ACHC are directed to
report known or suspected incidences of child abuse in accordance with state law and district
regulations. Employees shall cooperate with the child protective agencies responsible for
reporting, investigating and prosecuting cases of child abuse.
All employees are considered Mandated Reporters of abuse or neglect.
Employees shall report known or suspected child abuse to a child protective agency by telephone
immediately or as soon as practically possible and in writing within thirty-six (36) hours. The
reporting duties are individual and cannot be delegated to another individual.
Definition
1. Child Abuse, as defined by law, includes the following:
a. Physical abuse resulting in a non-accidental physical injury.
b. Physical neglect, including both severe and general neglect, resulting in a negligent
treatment or maltreatment of a child.
c. Sexual abuse including both sexual assault and sexual exploitation
d. Emotional abuse and emotional deprivation including willful cruelty or unjustifiable
punishment
e. Severe corporal punishment
2. Mandated Reporters are those people defined by law as child custodians, medical
practitioners and non-medical practitioners and include virtually all school employees. The
following clinic personnel are required to report: doctors, nurses, medical assistants,
receptionists, and counselors.
3. Reasonable Suspicion means that it is objectively reasonable for a person to entertain such a
suspicion, based upon facts that could cause a reasonable person in a like position, drawing when
appropriate on his/her training and experience, to suspect child abuse (Penal Code 11166).
Reporting Procedures
To report known or suspected child abuse, employee shall report by telephone to the local child
protective agency:
Child Protective Services
1200 South Drive
Hanford, CA 93230
Phone 582-3211 or 582-3241
The telephone report must be made immediately, or as soon as practically possible, upon
suspicion. The verbal report will include: a) name of the person making the report, b) name of
the child, c) present location of the child, d) nature and extent of any injury, e) any other
information requested by the child protective agency, including the information that led the
mandated reporter to suspect child abuse.
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Initials
ACHC New Employee Packet 10
At the time the verbal report is made, the mandated reporter shall note the name of the official
contracted, the date and time contracted and any instructions or advice received. Within 36 hours
of the telephone report, the mandated reporter must complete the mail a written report to the
local child protective agency. The written report shall include completion of the required
standard Department of Justice Form (DOJ SS 8572) available in the nurses’ station.
Employees reporting child abuse to a child protective agency are encouraged, but not required, to
notify the site administrator or designee as soon as possible after the initial verbal report by
telephone. If requested by the mandated reporter, the site administrator may assist in the
completion and filing of forms necessary for reporting. If the mandated reporter chooses not to
disclose his/her identity, s/he shall provide a copy of the written report without his/her signature
or name.
Legal Responsibility and Liability
1. Mandated Reporters have absolute immunity. Employees required to report are not civilly or
criminally liable for filing a required or authorized report of known or suspected child abuse.
2. A mandated reporter who fails to report an instance of child abuse, which he/she knows to
exist or reasonable should know to exist, is guilty of a misdemeanor and is punishable by
confinement in jail for a term not to exceed six (6) months or by a fine of not more than one
thousand dollars ($1,000) or both. The mandated reporter may also be held civil liable for
damages for any injury to the child after a failure to report.
3. The duty to report child abuse is an individual duty and no supervisor or administrator may
impede or inhibit such reporting duties. Furthermore, no person making such a report shall be
subject to any sanction.
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Initials
ACHC New Employee Packet 11
Avenal Community Health Center
Aria Community Health Center
Confidentiality Policy & Statement
Avenal Community Health Center is committed to the principal of fair and ethical business
practices and to ensuring confidentiality of records and related information for all patients,
employees and other clinic business.
Avenal Community Health Center gives full consideration to patients’ rights for privacy
concerning all aspects of their health care. All communications regarding their care will be
treated as confidential information. Access to any of the information is to be limited only to
individuals who have a legitimate purpose for the use of any given information.
All employees, volunteers and contracted providers who have access to information about
patients, employees or clinic operations which is of a confidential nature, will be prohibited from
discussing or revealing such information in any unauthorized manner.
Any breach of confidentiality (i.e. the unauthorized discussing or revealing of patient, employee
or clinic operating information), represents a failure to meet the professional and ethical
standards expected of all employees and constitutes a violation of this policy. If it is determined
that a breach of confidentiality has occurred, the employee may be subject to disciplinary action,
up to and including termination or employment.
This breach need not take the form of a deliberate attempt of breach of confidentiality, but will
include an unnecessary or unauthorized informal discussion of a confidential matter (i.e.
informal dialogue in the break room or hallways) for which the same rules will apply.
This policy and requirement to maintain confidentiality extends beyond the hours of work and
beyond the term of your employment at Avenal Community Health Center.
I hereby acknowledge receipt of this confidentiality policy, and I agree to be bound by such
policy, as stated above.
________________________________________________ ______________________
Signature Date
________________________________________________ ______________________
Witness Date
ACHC New Employee Packet 12
10 STEP QUICK REFERENCE HIPAA (PRIVACY) GUIDE (post in an accessible and prominent office location)
1. Use lowered voice for all verbal communication that might disclose personal
health information.
2. Never “call out” any information that might be considered as personal, e.g.
tests required or taken, test results, medications, devices used, etc.
3. Do not allow computer screens to be viewed, intentionally or
unintentionally, by unauthorized persons.
4. Exit all programs that might contain personal health information when
leaving a computer workstation for a period of time.
5. Be certain that “sign-in” sheets do not require “reason for visit” information.
6. All chart holders must effectively obscure patient information.
7. All email, written and faxed personal health information (PHI) must be
clearly marked “confidential” and contain a privacy warning.
8. Never leave files or folders open or unattended. Filing cabinets etc.
containing PHI must be secured and locked.
9. Do not share computer passwords. Change them regularly.
10. Take every precaution to control personal health information.
________
Initials
ACHC New Employee Packet 13
EMPLOYEE HIPPA COMPLIANCE SIGNATURE FORM
Employee: _____________________________________________
Date: _________________________
My Commitment to Compliance:
I have read and understand our office’s Employee HIPAA Compliance manual. I agree to do all I
can, within my area of responsibility to maintain up-to-date knowledge about federal and state
laws and program requirements. I will comply with these requirements to the best of my ability,
and to immediately let the Compliance Officer know if there is any where I feel our office is not
in Compliance with these laws and program requirements. Our policy is a simple, yet powerful
four-step process: Keep Up-to-date, educate comply, and audit/correct.
a. We seek to maintain up-to-date knowledge about federal and state law pertaining
to protection of our patients Protected Health Information.
b. We educate our employees and keep them up-to-date about federal and state law
as it applies to Protected Health Information.
c. Our policy is to comply with all federal and state law governing Protected Health
Information.
We desire that all our employees are particularly cognizant of the fact that protected health
information must be treated with utmost attention, accuracy, honesty, and integrity. We seek to
educate and carry out these policies with all our employees, managers, clinicians, and where
appropriate contractors and other agents.
I agree with our policy and will do all I can to comply with all regulatory laws pertaining to
personal health information. In understand that our office has an open door policy and I may
discuss any problems I feel may occur with PHI without worry of recourse with my supervisor or
other supervisors.
__________________________________ __________________________________
Signature of Employee Signature of Compliance Officer
ACHC New Employee Packet 14
Avenal Community Health Center
Aria Community Health Center
Policy & Procedure
DISASTER PLAN
The Clinic has developed emergency plans to handle casualties in the event of an internal or local
disaster. Every employee within the Clinic must function according to the plan in time of disaster.
All employees are required to know the disaster plans, and to be able to implement it on a moment’s
notice.
For an internal disaster, all patients and employees will evacuate the building, and congregate in the
parking lot in the safest spot near the center island. The receptionist will bring the patient sign-
in/check-out sheet to verify that all patients are accounted for. The Administrator or other designated
person will take roll call of the employees.
All employees will be in serviced on the disaster plans and on appropriate skills needed during a
disaster (i.e., use of a fire extinguisher). Disaster drills will be conducted at least semi-annually. At
least one of those drills should mock an earthquake.
Review of the Disaster plan and compliance will occur annually. Evidence of such review shall
be the signed review of these policies and procedures.
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Initials
ACHC New Employee Packet 15
Avenal Community Health Center 1000 Skyline Boulevard • P.O. Box 700 • Avenal, CA 93204-0700 • Phone (559)386-4500 • (559)386-0550
Each of you will play an important part in preventing the spread of infection. Observe the following
infection control principles to protect yourself and others from infections. In order to know how to control
or prevent infections, you should first have a basic understanding of how infections are transmitted, or
passed from on person to another. The “Chain of Infection” illustrates this process, and your role is to
break the “Chain of Infection”.
In order for an infection to be passed to another al six of the links of the chain must be present.
Microorganism Carrier Way Out Travel Way In Susceptible
Person
1. A MICROORGANISM (virus, bacteria, fungus) that causes the infection.
2. A CARRIER is a patient or health-care worker, who carries the microorganism.
3. A WAY OUT of the carrier, such as coughing, sneezing, etc.
4. A METHOD OF TRAVELING such as though the air, through direct physical contact or through contaminated
hands, linens, towels, instruments, bandages, etc.
5. A WAY INTO ANOTHER PERSON, such as breathing, swallowing, or a break in the skin.
6. A SUSCEPTABLE PERSON who doesn’t have resistance and becomes infected.
INFECTION CONTROL MEASURES BREAK THE INFECTION CHAIN by reducing the number of
microorganisms, controlling travel, using barrier precautions to prevent entry into another person, and
immunizing susceptible employees against vaccine preventable illness.
HANDWASHING or USE OF ALCOHOL-BASED HAND RUBS is the single most
effective way to stop the spread of infection (break the chain of infection
Wash or gel your hands when:
You arrive at work
After using the restroom
Before eating, drinking or handling food
After patient contact
After touching blood, body fluids, secretions,
excretions, and contaminated items, whether or
not gloves are worn.
Immediately after gloves are removed
Note: Hands must be washed when they are
visibly soiled or exposed to blood or OPIM
(other potentially infectious materials).
How to wash your hands:
Wet your hands with warm running water.
Keeping hands lower than elbows, apply hand
washing agent.
Distribute hand washing agent thoroughly over
hands
Vigorously rub hands together for at least 10-15
seconds covering all surfaces of the
hands and fingers with particular attention to
-----the fingertips and nails
Rinse under running water.
Dry hands with a single use paper towel.
Use paper towels to turn off the faucet (this
helps keep your hands clean not touching the
dirty faucet).
How to gel your hands:
Apply to palm of one hand. Rub hand together covering all areas of
hands and fingers until hands are dry.
_____________ Initials
ACHC New Employee Packet 16
Bloodborne Patogens
Question and Answer
What is a Bloodborne Pathogen? Name two
Define Universal Precautions
Give at least 3 examples of workers who are at risk of exposure to bloodborne pathogens.
List three ways exposure to bloodborne pathogens commonly occurs.
Describe at least 5 key aspects of a bloodborne pathogen. Exposure Control Plan.
ACHC New Employee Packet 17
Name three PPEs
List three important steps to take if exposed to a bloodborne pathogen.
Print Name
Signature and Date
ACHC New Employee Packet 18
Avenal Community Health Center
Aria Community Health Center Policy & Procedures
ACKNOWLEDGEMENT
I have reviewed the Policy and Procedures for Avenal Community Health Center, outlining both
my privileges and obligations as an employee. I understand that I am responsible for reading and
familiarizing myself with the material in the Policy and Procedures, which describes the policies
governing my employment. I further understand that the Clinic may, at its sole and absolute
discretion, with or without prior notice, supplement or rescind the rights and responsibilities
identified in the policy and procedure manuals.
No statement(s) in this Policy or in other statement(s) of policy, including statements made
during performance appraisals, are to be construed either as an expressed or implied promise of
continuing employment.
Employee Printed Name
Employee Signature Date
Within 30 days of hire, and annually thereafter, each employee will review the following:
1. Clinic Policy and Procedures
2. Disaster Plan
3. Infection Control Procedures
4. Safety Manual
5. Employee Handbook
This review is a prerequisite for continued employment. By signing below, the employee
acknowledges that they have reviewed the documents noted above.
Employee Printed Name
Employee Signature Date
ACHC New Employee Packet 19
Avenal Community Health Center 1000 Skyline Boulevard • P.O. Box 700 • Avenal, CA 93204-0700 • Phone (559)386-4500 • (559)386-0550
Memo: GOSSIP
Gossip can occur from misunderstandings or from someone who is intent on being destructive or
hurtful. The initiation or perpetuation of gossip is a waste of time and energy, and is completely
unacceptable!
Recent surveys show that gossip is one of the top three complaints found in the workplace.
When people feel betrayed by malicious or unfounded rumors and gossip, the entire clinic can
suffer. Low morale and contention can affect patient care. In addition, gossip outside the office
can put the practice at risk for unauthorized disclosure of protected health information, and are
destructive to the reputation of individuals and the organization.
Though the word ‘Gossip’ does not appear in our Employee Policy Manual, it would fall under
at least the ‘Harassment’ section on page 12, which starts with sentence ...’Our clinic prohibits
any form of harassment.’ Each and every person serving in our organization is required to
acknowledge that if you initiate or perpetuate gossip, rumor or innuendo, you may be
disciplined, up to and including immediate termination. Due to the nature of gossip, this will
apply whether you participate in gossip in the workplace or anywhere else.
Please feel free to ask questions or make comments to your supervisor or administrative
personnel.
I acknowledge I have read this memo, and understand that if I initiate or perpetuate
gossip, rumor or innuendo, I may be disciplined, up to and including immediate
termination.
Signature ____________________________ Date: ____________________
Print Name___________________________
ACHC New Employee Packet 20
Alphabewhat?
I. Put the following names in alphabetical order (use pencil)
Moron, Lorena Moreno, Edgar Morrillon, Luis Mora, Francisco
Morado, Emily Morfin, Leticia Morales, Maria
1.________________ 4. ________________ 6.________________
2. ________________ 5. ________________ 7. ________________
3. ________________
II. Number the following names from 1-6 in alphabetical order:
___Rodrigues, Jesus ___Rodriguez, Maria ___Rodriguez, Juan
___Rodriguez, Martha ___Rodrigues, Lourdes ___Rodriguez, Juana
III. Place in the correct order
Ana Ayala Rios, Rafael Angelica Dominguez
Teresa Calvillo Navarro, Leonardo Ferguson, Zachary
Diaz, Isabel Perez, Jose Lopez, Jose
Lopez, Jose Luis
1.__________________ 5. __________________ 8. __________________
2. __________________ 6. __________________ 9. __________________
3. __________________ 7. __________________ 10. _________________
4. __________________
IV. Number the following list of names. Make the first to come alphabetically #1:
___Chavez, Sebastian
___Chavez, Sebastian Jr.
___Chavez, Sebastian J.
___Chavez, Sebastian Sr.
___Chavez, Sebastian
ACHC New Employee Packet 21
Circle the names that are in the wrong place then write them in order in the column on the
right.
1. Ochoa, Humberto
2. Ochoa, Hector
3. Ochoa, Israel
4. Ochoa-Cantu, Nellie
5. Ochoa, Maria
6. Ochoa, Maria Teresa
7. Ochoa, Maria
8. Ochoa, Patricia
9. Ochoa, Olivia
10. Ochoa, Oliver
11. Ontiveros, Raquel
12. Ochoa-Rivera, Luis
13. Ochoa, Veronica
14. Ochoa, Victor
15. Ochoa, Victor Sr.
16. Olivera, Alicia
17. Olivera, Angela
18. Olivera, Angel
19. Oliva, Beatrice
20. Perry, Fred
21. Perry, Frances
22. Perez, Jose
23. Perez, Jose Luis
24. Perez, Jose Maria
25. Perez, Jose Angel
26. Pratt, Michael
27. Pratt, Michelle
28. Pratt, Melody
29. Ponce, Jesus
30. Ramierez, Mayra
31. Ramierez, Maria
32. Ramierez, Neida
33. Rivera-Ochoa, Pablo
34. Smith, Jesse
35. Smith, Gordan
36. Sanchez, Cristian
37. Sanchez, Christian
38. Solorio, Esteban
39. Solorio, Daniel
40. Soltero, David
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