on line orientation application & acknowledgement€¦ · application & acknowledgement now...

Form # HR 1023 Revised 8/17, 9/17, 10/17 of 6

On−line OrientationApplication & Acknowledgement

Now that you have reviewed the material, please complete each section by typing into theappropriate fillable area. Once completed, print and sign each document with your handwrittensignature. We do not accept electronic signatures at this time. We ask you to carefully reviewbefore sending to ensure that all signatures are present. Failure to complete could result in adelay of processing.

You will be given a fax line and/or email address with additional instructions on how to returnthe packet to the appropriate department. You may be asked to provide and complete additionalpre−boarding health assessment requirements in addition to this packet. Thank You.

General Information Application (please print)

Today’s Date:__________________________

Name:____________________________________________________________________________________________

Date of Birth:________________________________ Social Security #:________________________________

*** Please note: Birthdate and social security number will be used for background screening processes.

Home Address:_____________________________________________________________________________________

Cell Phone #:___________________________________ Alternate #:___________________________________

Email Address:_____________________________________________________________________________________

Educational InformationPlease provide information of current school of attendance or institute where degree was obtained, if applicable.

School: ___________________________________________________________________________________________

Address: __________________________________________________________________________________________

Degree Information (if applicable)

Degree:________________________________________ In Field of:________________________________________

Date Obtained:___________________________________ Anticipated Date:_________________________________

First Middle Last

Street Address City State Zip Code


Please check which is applicable:❏ Independent Contractor❏ Volunteer (Hospital Site)❏ Volunteer (Hospice Site)

❏ Non−Employee: Provides Patient Care or Service❏ Student Observer/Shadowing: Less than 4 hours❏ Student Observer/Shadowing: Greater than 4 hours


Work HistoryPlease provide information of current employer or last position held, if applicable.

Employer:________________________________________________ Title:___________________________________

Dates of Employment:____________________________ to ____________________________

Supervisor:_______________________________________ Email:__________________________________________

Address:__________________________________________________________________________________________

Phone #:___________________________________

Emergency ContactIn the case of an emergency, please list who to contact.

Name #1: _________________________________________________________________________________________

Address: __________________________________________________________________________________________

Cell Phone #:______________________________________ Alternate #:______________________________________

Email Address:_____________________________________________________________________________________



CertificationPlease check for those applicable:

❏ Basic Life Support (BLS) / CPR *Required for students if observing more than 4 hours. *Amercian Heart Association only.

❏ Advanced Cardiac Life Support (ACLS)

Expires:_____________________

Expires:_____________________

*Please attach photo of certification card and include with application submission.

ReferencesYou may include previous supervisors and/or instructors, but we ask that you do not list relatives.

Reference #1:______________________________________________________________________________________


Email Address:_____________________________________________________________________________________

Reference #2: _____________________________________________________________________________________


Email Address:_____________________________________________________________________________________

Form # HR 1023 Revised 8/17, 917, 10/17 of 6

Release of Information

The applicant specifically authorizes the hospital and its authorized Representatives to consult with any thirdparty who may have information bearing on the applicant’s professional qualifications, credentials, clinicalcompetence, character, health status, ethics, behavior, or any other matter reasonably having a bearing on theapplicant’s qualifications. This authorization includes the right to inspect or obtain any and allcommunications, reports, records, and documents from said third parties. The applicant also specificallyauthorizes said third parties to release said information to the hospital and its authorized representatives uponrequest.

To the fullest extent permitted by law, the applicant releases from any and all liability, extends absoluteimmunity to, and agrees not to sue the hospital, it’s authorized Representatives and third parties with respectto any acts, communications or documents, recommendations or disclosures involving the applicant.

(a)

(b)

_________________________________________________________________Printed Name

_________________________________________________________________ ____________________________Signature Date


On−line OrientationAcknowledgement

I acknowledge the receipt of HaysMed’s On−Line Orientation Manual. I have received variousmaterial and instructions on the topics listed below.

● Roles & Responsibilities● Service Excellence● Patient Rights & Responsibilities● Cultural Diversity● Professional Image● Harassment Free & Workplace Violence● Environmental/Occupational Safety● Parking/Lost & Found● Infection Prevention● Corporate Compliance● HIPAA Privacy & Security of Health Information● Quality Improvement/Risk Management Program● Tobacco Free Environment● Document Management System

_________________________________________________________________Printed Name

_________________________________________________________________ ____________________________Signature Date


Orientation Manual Role& Responsibility Acknowledgement

I agree to:

● Adhere to general rules, policies and regulations of HaysMed● Abide by the Tobacco Free policy● Abide by the cell phone and social media policy● Act professionally and refrain from making inappropriate comments or gestures toward employees, patients, and family members● Abide by the corporate compliance and infection prevention/control policies● Respect patient’s right to privacy and maintain confidentiality at all times● Report any suspicious circumstances or patient/quality concerns to assigned staff member● Work in collaboration with assigned staff member and treat individual with respect● Wear proper identification badge and abide by facility dress code policy● Notify assigned staff member when arriving and leaving facility● Only use computer access as appropriate in order to carry out assigned duties● Not share my password with anyone● Participate in E−learning policy● Attend required mandatory compliance meetings● Treat hospital property with respect● Return all property provided to assigned staff member at end of facility placement● Understand that I will be responsible for the cost of any damaged or lost property● Refrain from posting information on social media sites● Refrain from cell phone usage and texting during placement at facility

_________________________________________________________________Printed Name

_________________________________________________________________ ____________________________Signature Date


On−line Manual Orientation Exam

Please note: Answers can be found by reviewing the orientation manual.

1. What is the mission of HaysMed?__________________________________________________________

2. Our facility is designed to contain a fire behind closed doors to allow firefighting efforts to occur. If you

discover a fire recall the RACE acronym. What does it stand for?

R__________ A___________ C___________E___________

3. What is the purpose of Standard Precautions?

_____________________________________________________________________________________

4. Who is the Compliance Officer at HaysMed?_________________________________________________

5. What is the purpose of the Code of Conduct?

_____________________________________________________________________________________

6. What does PHI stand for? ________________________________________________________________

7. How do you lock down your computer before leaving? _________________________________________

8. Who is the Privacy Officer at HaysMed? ____________________________________________________

9. What is the software product used for reporting an incident?_____________________________________

10. The Forms Committee is responsible for?___________________________________________________

_________________________________________________________________Printed Name

_________________________________________________________________ ____________________________Signature Date

CODE OF CONDUCT - HIPAA COMPLIANCE CERTIFICATION I hereby acknowledge that I have attended a training session to review Hays Medical Center’s (“HaysMed’s”) Code of Conduct. I understand I may access the Code of Conduct on HaysMed’s intranet and internet websites. I understand my obligations and responsibilities as set forth in the Code of Conduct and agree to be bound by the principles, standards, and policies contained in the Code currently, and as they might be amended from time to time. I hereby acknowledge that I have attended a training session to review the HIPAA Privacy regulations. I understand that I may access HaysMed’s Notice of Privacy Practices on HaysMed’s intranet and internet websites. I understand my obligations and responsibilities as set forth in the Notice of Privacy Practices and agree to be bound by standards contained in the Notice currently, and as they might be amended from time to time. I hereby acknowledge that I may access the Notice of Privacy Practices for the HaysMed Employee Health Care Plan and the HaysMed Health Care Flexible Spending Account Plan (“HaysMed Group Health Plans”) on HaysMed’s intranet and internet websites. I hereby consent to receive the HaysMed Group Health Plans’ Notice of Privacy Practices electronically. HaysMed will e-mail such Notice of Privacy Practices to my HaysMed e-mail account. I understand that copies of this Notice of Privacy Practices are available to me at any time by calling the Privacy Officer for the Haysmed Group Health Plans, Christy Stahl, at (785) 623-2188, or e-mailing her at [email protected]. If, at any point, I do not wish to receive the HaysMed Group Health Plans’ Notice of Privacy Practices electronically, I must notify Christy Stahl in writing.

I hereby acknowledge that I have attended a training session to review the HIPAA Security regulations. I understand and agree to be bound by the standards contained in the regulations currently, and as they might be amended from time to time. I understand that in the event I violate HaysMed’s Code of Conduct, Notice of Privacy Practices, or the Security regulations, I will be subject to disciplinary action, up to and including, termination of my relationship with HaysMed. I further understand that HaysMed will only tolerate conduct on the part of all Associates that furthers organization-wide integrity and ethics. I represent that I am in compliance with the Code of Conduct at the present time, with the following possible exceptions: (You should include a statement concerning any personal business situation, conflict of interest, or other matter which you believe is or may be a violation of the Code of Conduct). I agree to report any suspected or known violation of the Code of Conduct, the HaysMed Notice of Privacy Practices, the HaysMed Group Health Plans’ Notice of Privacy Practices, and/or the Security regulations. Associate’s Signature Associate’s Number & Department Associate’s Name (printed) Date Signed

mailto:[email protected]

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Associate Confidentiality

Agreement

Name (Printed)

(referred to herein as “You”)

Department

Definitions

As used herein, the following terms shall have the following meanings:

1. “Confidential Information” includes any information, regardless of the manner in which it is

communicated (e.g., oral, paper, electronic, observed) or maintained (e.g., oral, paper, electronic),

received by Hays Medical Center (“HaysMed”) or any of its agents or Associates that falls into

one or more of the following categories:

Protected Health Information: Information relating to the past, present, or future physical or

mental health or condition of an individual; the provision of health care to an individual; or the

past, present, or future payment for the provision of health care to an individual. Protected Health

Information includes a patient’s demographic information, e.g., address, telephone number,

employer, date of birth, religious affiliation, next of kin, and identification numbers.

Personnel Information: Information relating to a person’s status as a HaysMed Associate,

including but not limited to compensation, employment records, accommodations, performance

reviews, and disciplinary actions.

Business Operations Information: Information relating to HaysMed’s business operations,

including but not limited to financial and statistical records, strategic plans, internal reports,

memos, contracts, pricing, staffing levels, supplier information, remote site information, peer

review information, communications, proprietary computer programs, source code, and proprietary

technology.

Third-Party Information: Information belonging to a third party utilized by HaysMed for

limited purposes pursuant to an agreement with the third party, including but not limited to

computer programs, client and vendor proprietary information source code, and proprietary

technology.

Personal Information: Information relating to the personal life of any patient, HaysMed

Associate, or member of the HaysMed Medical Staff.

2. "Receive," "Receiving," and "Receipt" means, with respect to Confidential Information, to come

into possession, custody, or control; to perceive; to create; to gain the ability to come into

possession, custody, or control; or to gain the ability to perceive Confidential Information in

whatever form (oral, visual, written, electronic, or otherwise).

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3. “Use” means, with respect to Confidential Information, accessing, reviewing, employing,

applying, utilizing, examining, or analyzing such information, or sharing or discussing such

information with other HaysMed Associates.

4. “Disclose” means, with respect to Confidential Information, release, transfer, provision of access

to, or divulging in any other manner such information to a person or entity who is not a HaysMed

Associate.

5. “Associate” includes HaysMed directors, officers, employees, volunteers, students, trainees,

independent contractors, and others who perform work for HaysMed regardless of the location at

which they work, whether or not they are compensated for such services.

6. “HaysMed Computer Systems” includes computer files, computer hard drives, local area

network, wide area network, mainframe, electronic mail, internet access, intranet access,

electronic medical records, electronic order entry, portable equipment, HaysMed issued mobile

devices (e.g., flash drive, memory card, Blackberry, PDA, cell phone), and any device where

Confidential Information is maintained.

Duties and Obligations

In performing your duties as a HaysMed Associate, you may receive, create, use, disclose, or transmit

Confidential Information. As a condition of and in consideration of your receipt of Confidential

Information and your continued employment or affiliation with HaysMed, you acknowledge and agree to

the following:

1. You understand that you have no right or ownership interest in any Confidential Information

which you may receive or create. HaysMed may, at any time and for any reason, revoke your

password, access code, or any other authorization you have that allows you to receive, use,

disclose, or transmit Confidential Information in any form.

2. You understand that you must respect and maintain the confidentiality of all discussions,

deliberations, patient records, and any other information associated with individual patient care,

risk management, and/or peer review activities. You must not disclose any discussion,

deliberation, patient records, or any other patient care, risk management, or peer review

information except to individuals authorized to receive it according to HaysMed’s policies and

procedures.

3. You understand that your obligations under this Agreement with respect to Confidential

Information shall continue after termination of your relationship (employment or otherwise) with

HaysMed. On termination of your employment or affiliation with HaysMed you must return all

Confidential Information in your possession or control. You understand that your privileges

hereunder are subject to periodic review, revision, and, if appropriate, renewal.

4. The use and disclosure of Confidential Information is governed by Federal and State laws and

regulations as well as HaysMed policies and procedures. The purpose of these specific

requirements is to guarantee that Confidential Information remains confidential, i.e., such

information shall be used and disclosed only as necessary to accomplish HaysMed’s mission.

You shall be familiar with and adhere to all applicable laws and regulations and HaysMed

policies and procedures concerning the use and disclosure of Confidential Information.

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5. You shall actively participate in educational opportunities made available to you concerning

proper safeguards for Confidential Information and uses and disclosures of Confidential

Information as part of your job duties.

6. If you have any question concerning whether certain information constitutes Confidential

Information, you shall bring the matter to your supervisor or HaysMed’s Privacy Officer for

direction.

7. You shall appropriately safeguard Confidential Information so as to prevent any inappropriate use

or disclosure of such information. You shall be knowledgeable of and adhere to HaysMed

policies and procedures regarding safeguarding of Confidential Information. If you have reason

to believe the confidentiality of information may have been compromised, you shall report such

concerns to HaysMed’s Privacy Officer immediately.

8. You shall use and disclose Confidential Information only to the extent necessary to perform your

assigned job duties, and only in the minimum amount necessary to satisfy your duties. Such use

and disclosure shall be in a manner consistent with applicable HaysMed policies and procedures.

Your use or disclosure of Confidential Information for any reason other than the performance of

your assigned job duties or your failure to conform to applicable policies and procedures shall

constitute misuse of Confidential Information. You understand that any misuse of Confidential

Information may be grounds for discipline (up to and including termination of your employment

or other relationship with HaysMed) and/or the initiation of legal action (including criminal

charges) against you.

9. If you have any question concerning whether your assigned job duties permit you to use or

disclose certain Confidential Information in a particular manner, you shall bring the matter to

your supervisor or HaysMed’s Privacy Officer for direction. If you have any question concerning

the application of a particular HaysMed policy or procedure to a particular use or disclosure of

Confidential Information, you shall bring the matter to your supervisor or HaysMed’s Privacy

Officer for direction.

10. In performing your job responsibilities, you shall not knowingly include or cause to be included

in any record or report a false, inaccurate, or misleading entry. Nor shall you make or cause to be

made any false, inaccurate, or misleading statement to any person. If you become aware of false,

inaccurate, or misleading information contained in any record or report, or a false, inaccurate, or

misleading statement, you shall report the matter to your supervisor and cooperate in taking all

steps necessary to correct the record, report, or statement pursuant to HaysMed policies and

procedures.

11. You shall comply with HaysMed policies and procedures concerning the alteration, deletion, or

destruction of Confidential Information in any form. If you have any question concerning such

policies and procedures, you shall bring the matter to your supervisor or HaysMed’s Privacy

Officer for direction. If you have any reason to believe such policies and procedures have been

violated, you shall report such concerns to HaysMed’s Privacy Officer immediately.

12. You shall not use HaysMed Computer Systems (including, but not limited to, any electronic

medical record, portable equipment, or mobile device) to access any information relating to you,

your family members, or any other person for any reason except as necessary to perform your

specific job duties.

13. You shall not access the patient status boards in the electronic medical record unless there is no

other way for you to perform your job duties.

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14. Except as necessary to perform your specific job duties, you shall not discuss or disclose

Protected Health Information to any person (this includes an Associate who does not require

access to such information to carry out his/her job duties) or engage in conversations (in person,

by telephone, or electronically) concerning the fact that a person is or has been a patient of

HaysMed or concerning any information relating to such patient (e.g., symptoms, behavior,

diagnosis, procedures, outcome) even if you do not identify such person by name or otherwise.

Nor shall you post any such information on the internet (e.g., discussion boards, listserves,

Facebook, Twitter, LinkedIn). You understand this limitation is intended to protect the

Confidential Information created, maintained, obtained, or observed during your affiliation with

HaysMed related to patient care, and is not intended to limit your right to discuss conditions of

your employment.

15. You shall not post to any social networking site from the beginning of a given work shift until it

ends, unless your job description requires such posts to be made as part of maintaining a

HaysMed sponsored social networking page.

16. If you become aware through any means (including, but not limited to, personal observation or

reports or complaints received from business associates, patients, patients’ family members and

other advocates, or other Associates) of a possible unauthorized use or disclosure of Protected

Health Information, you shall report such matter to the HaysMed Privacy Officer immediately.

You understand that you will be subject to disciplinary action, up to and including termination of

your employment or other relationship with HaysMed, if you fail to make a timely report.

17. You shall not download or store Protected Health Information on the hard drive of any computer

or mobile device used by you, regardless of whether such computer or device is owned by

HaysMed or you. You shall not transmit Protected Health Information in electronic form (e.g.,

via e-mail) unless such information has been properly encrypted. You shall obtain encryption

assistance from the Information Technology Department as needed.

18. You understand that HaysMed monitors each and every time HaysMed Computer Systems are

accessed. You understand that any action you take in a HaysMed Computer System will be

tagged with your unique identifier as established in your user profile, and such actions can be

traced back to you including, but not limited to, access to patient status boards or an individual’s

electronic medical record, e-mail messages sent and received, and web sites visited. You

understand HaysMed conducts regular audits of such access pursuant to HaysMed policies and

procedures, and that disciplinary action may be taken against you if such an audit indicates you

accessed records, sent or received e-mail messages, or visited websites without a legitimate

reason for doing so.

19. You shall safeguard and shall not disclose to any person your computer password, access code, or

any other authorization you have that allows you to access HaysMed Computer Systems. You

shall be responsible for all activities undertaken using your password, access code, and other

authorization, and you shall be responsible for any misuse or wrongful disclosure of Confidential

Information resulting from the use of your password, access code, or other authorization. You

shall not utilize any other person’s computer password, access code, or any other authentication

to access any HaysMed Computer System.

20. If you believe the security of your computer password, access code, or any authorization you

have that permits you to access HaysMed Computer Systems has been compromised, or if you

believe any computer or mobile device (e.g., flash drive, memory card, Blackberry, PDA, cell

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phone) used by you to access or store Confidential Information has been misplaced, stolen, or

otherwise compromised, you shall immediately report such matter to the HaysMed Privacy

Officer.

21. You shall respect the ownership of proprietary software. You shall not make unauthorized copies

of any software, even if the software is not physically protected against copying, nor shall you

operate any non-licensed software on any computer provided by HaysMed.

22. Regardless of any changes that may occur to your duties, status, job title, and/or terms of your

employment or affiliation with HaysMed, you understand and agree that the terms of this

Confidentiality Agreement will continue to apply.

By signing this document, you certify that you have reviewed the foregoing Confidentiality Agreement,

have been provided with an opportunity to ask questions concerning its terms, and understand the duties

and obligations it imposes on you. You hereby agree to the duties and obligations as stated in this

Confidentiality Agreement. You understand that this signed and dated document will become part of

your permanent personnel record.

__________________________________

Signature Date

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