SMH Personnel Action Form: Non

SMH
Personnel Action Form: Non-Employees
Section 1: Applicant to complete
Name:
DOB:
Mailing Address:
City:
State:
Physical Address:
Zip:
Email Address:
Home Phone:
Cell Phone:
Alternate Phone:
Type: □ Medical Student/PA/NP(Clinical) □ Health Science or High School Student(Observation) □ Job Shadow (Observation)
School/Organization(if applicable):_______________________________ Dates onsite at SMH:_______________________________
Participant Signature:____________________________________
Date:_________________
Section 2: Administration to complete
Drug Screen
Date Performed:_________
Date Performed:_________
Paperwork
Background:
Date Performed:_________
Date Cleared: _________
Date Cleared: _________
Date Cleared: _________
Department Name
Employee Health
Dept. #
Dept. Manager
Preceptor
Badge
□ Programmable:______
□ Non-programmable:______
Time Frame
Notes:
Department Manager/Admin Signature
Date
Human Resources Signature
Form must be returned to Human Resources.
Rev. 12/2014
Date
Code of Conduct
How we promote our values…
Integrity
De
 “You can count on me”.
Follow through with
requests.
 Do the right thing.
Excellence
 Provide absolutely
the best care for every
patient every day.
 Recognize and praise
 Be good customers.
others for their
 Exhibit a commitment to
accomplishments.
co-workers, customers, and
the organization by being
honest, trustworthy, and
loyal.
 Support your co-workers.
Do not undermine.
responsibilities of your
job.
 Assume ownership of the
chastise, or embarrass
 Know how to operate
applicable equipment.
 Develop competent,
experienced, motivated
 Welcome new staff and
 Work as a team to meet
customer needs.
 Motivate others by
the hospital dress code
enhancing their
and portray a positive
self-esteem.
 Treat each other with
 Accept the
accountable.
Collaboration
appearance.
as if you were the owner.
problem: do not blame,
Professionalism
 Dress in accordance with
 Take care of the facility
 Hold each other
professionals who exceed
standards for quality care.
promote teamwork.
Ownership
others.
 Take responsibility for
being informed.
 Listen to each other’s
concerns in ways that
show you care.
Respect
 Send the message,
“You are important”.
 Respect the personal
rights of others.
 Introduce yourself,
 “Think outside the box”
smile, make eye
 Tap employees
contact, initiate
courtesy and respect,
potential by seeking
rudeness is never
information, coaching,
appropriate.
mentoring, and positive
he/she is the most
reinforcement.
important person in our
 Wear the appropriate
name badge.
 Confidentiality is
everyone’s responsibility.
 Offer to help one
another.
assistance.
 Treat everyone as if
facility.
 You only have one
chance to make a first
impression.
Developed by the
Standards Team
Sheridan Memorial Hospital
CONFIDENTIALITY AGREEMENT
Sheridan Memorial Hospital (SMH) recognizes the importance of the protection of
confidential information concerning patients, their families, medical staff, co-workers and
the operations of the Hospital. It is the intent of Sheridan Memorial Hospital and the
undersigned individual to maintain the privacy of Protected Health Information (PHI) in
compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
the privacy regulations published by the U.S. Department of Health and Human Services
(DHHS), and any other applicable State and Federal laws and/or regulatory agency rules
and regulations.
“Confidential Information” denotes all information acquired by an individual in the course
and scope of their employment and/or their association with Sheridan Memorial Hospital
whether that information is obtained by discussion (direct or overheard), consultation,
examination, treatment, and or direct access to records.
It is the obligation of the undersigned individual to maintain the confidentiality and privacy
of PHI to the best of their ability and to divulge/share only the minimum amount of PHI
necessary for another authorized individual with a valid “need to know” to do their assigned
tasks.
As a member of Sheridan Memorial Hospital’s workforce, I
(Print Name) ______________________________________ do hereby agree that I will:
1.
2.
3.
4.
Protect the confidentiality of patient and hospital information.
Not divulge/share unauthorized information to any source.
Not access or attempt to access information other than that information which i have
authorized access to, and a need to know, in order to complete my assigned tasks.
Report breaches of this confidentiality agreement by others to Sheridan Memorial
Hospital’s Privacy Officer. I understand that failure to report breaches is an ethical
violation which may subject me to disciplinary action up to and including termination.
I have read and agree to adhere to the conditions of this confidentiality agreement. I also
acknowledge that any violation of the above conditions can result in disciplinary action up to and
including termination.
____________________________
SIGNATURE
__________________
DATE
____________________________
WITNESS
___________________
DATE
Approved: 02-15-06
Employee Emergency Information
Employee Name: ____________________________________Date:_____________
Whom should we call in case of emergency?
Name of person to contact?_______________________________________________________
Phone Number:_______________________ Alternate Phone Number:____________________
Address (Optional):_______________________________________________________________
Relation to Employee:_____________________________________________________________
If we cannot reach the person above, whom should we call?
Name of person to contact:_______________________________________________________
Phone Number:______________________ Alternate Phone Number:_____________________
Address (Optional):______________________________________________________________
Relation to Employee:____________________________________________________________
Consider wearing a medical alert bracelet if you have any medical conditions or allergies to
medication that should be made known to emergency personnel.
Physician Name: (Optional)
Physician Phone:
Employee Signature
Date
Employee Name Badge Request
/
Name to appear on name badge
(please print)
Full Name (first & last)
Examples: Registered Nurse
CNA
Phlebotomist
Nutrition Serv. Aide
Position Title
Department
Employee Signature
Date
HR Office Use Only:
Please Select One:
□ Medical Student/PA/NP
□ Health Science Student(Observation)
Badge Number
□ High School Student(Observation)
Check-Out Date
□Job Shadow
Check-In Date
Office Use Only:
Employee #:
User ID:
Security Card #:
Date Card Printed:
Access Level #:
Date Security Levels Entered:
Picture Emailed to Employee Health:
Email Sent to Nursing Staff Coordinator:___________________
Authorized Payroll Deduction: Yes No
Rev. 12/15/14