NEW EMPLOYEE CHECKLIST AND ORIENTATION CHECKLIST EMPLOYEE NAME ______________________ DOH ____________ STATUS F/T P/T DOO ____________ _______________________________________________________________________________ _______________________________________________________________________________ THE FOLLOWING IS REQUIRED WITHIN 7 DAYS OF EMPLOYMENT: DEPT HEADS COMPLETE ITEMS 1-7 BEFORE ORIENTATION: 1= APPLICATION _____ 2= ATTENDANCE RECORD _____ HISTORY & PHYSICAL _____ 3= FORM I-9 _____ TB SCREENING _____ 4= W-4 ______ FACILITY ORIENTATION _____ 5= COPY OF LIC.CERT. ______ CNA ORIENT SHEET _______ 6= REFERENCE CHECK _______ CPR CARD ______ 7= Status Sheet _____ 24 HOUR INSERVICE ACKNOWL ______ EMPLOYEE WORKRULES _______ RECEIPT OF SAFETY BOOK ______ PATIENTS RIGHTS ______ EMERGENCY QUESTIONNAIRE ______ MONEY AND PATIENTS _______ CNA COMPETENCY TEST ______ TIME CARDS ______ SAMPLE JOB DESCRIPTION LIC. ______ LIC. ORIENT. MEDS. ______ SAMPLE JOB DESCRIPTION CNA ______ WORKER COMP INFORM ________ DISABILITY INSURANCE PROVISIONS ______ LICENSE MEMO TASK LIST _______SAFETY AND ORIENTATION FILM _____ UNIVERSAL PRECAUTIONS ______ CHEMICAL HAZARDS _______ PHILOSOPHY OF CARE ______ CREDIT UNION INFOR ____ SIGN IN SHEET INFOR _____ EE0--AA COMMITMENT ______ CHARGE BOOK INFOR _____ READ FIRE PROCEDURES MANUAL ____ MAINTENANCE LOG ____ DISASTER PLANS ____ 02 TANK ____ CPR FILM & TEST _______ TELEPHONE RULES ____ NON-NURSING PERSONNEL ORIENTATION _____ FEDERAL & STATE REG. ____ NON-NURSING PERSONNEL JOB DESCRIPTION ______ MEDICAL BENEFIT SUMMARY_____ SAFETY COMMITTEE INFORMATION ______ EDUCATIONAL PROFILE ______ REVIEW ON CHARTING REQUIREMENTS _______ THEFT AND LOSS PROGRAM ____ FIRE & SAFETY INSTRUCTIONS _____ ADVANCE DIRECTIVES _______ PERSONNEL RESPONSIBILITY ______ ABUSE POLICY _______ COMPLETION ORIENTATION PROGRAM ______ & _____ HEPATITIS B VACC PROG ______ WRITTEN EXPOSURE CONTROL PLAN________ Shown Fire Extinguishers and Operation Procedures ________ Shown Time Clock and Explained Use Of Time Clock Procedures _______ Cautioned To Clock In and Out On Time _______ Overtime Policy Explained_______ Evaluation Review Explained_________ Shown Employees Lounge and Restroom_______ Starting Salary Explained____________ Informed of Labor Laws As Posted_____ 3-Month Probationary period explained___________ Given Instruction Regarding: A) Personal Appearance ____ B) Attitude in all Areas_______ C) Personal Conduct_____ D) Patient and relatives relationship______ E) Proper attire for Position desired________ Asceptic Technique Orientation_______ Lifting Policy______ Availability Record________ Page 1 of 2 NEW EMPLOYEE CHECKLIST AND ORIENTATION CHECKLIST =============================================================================== ACKNOWLEDGEMENT ______________________________________________________________________________ =============================================================================== I have received my copies of the facility personnel policies,fire and evacuation plan and disaster plan,and job description of my assigned position. I have read and understand the Personnel Policies of the facility and accept them as a condition of employment. I have read the fire and disaster plan and agree to familiarize myself with the information in these books in order to know the procedures to follow in case of fire or disaster involving the facility. I have read and understand the job description containing duties of my assigned position. I agree to perform but not be limited to the stated duties. By request of my supervisor or / department head, I will serve as needed. It is understood that information in these facility books are subject to change by the facility author or administrator. It is further understood that personnel of the facility are notified of such changes through the usual channels DSD/Business office. I HAVE RECEIVED INFORMATION ON AND REVIEWED ALL OF THE FOLLOWING ITEMS LISTED ABOVE. EMPLOYEE NAME _____________________________________ COMPUTER INPUT __________ DATA INDEX CARD __________ ACTIVE ___________ INACTIVE ___________ CC: ADM CC: DON Page 2 of 2