DATE

HEALTHCARE ASSOCIATE EMPLOYMENT APPLICATION

Position Applied For: __________________ Date Available: ___________________

PERSONAL INFORMATION
NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY NO.
(Type just the numbers)
STREET ADDRESS PREFFERED NO.

ALTERNATE NO.
CITY, STATE, ZIP CAN WE TEXT? ☐ YES ☐ NO

PLEASE LIST OTHER NAME(S) BY WHICH YOU ARE KNOWN

E-MAIL ADDRESS
NOW OR IN THE PAST:

PLEASE INDICATE THE BEST TIME TO CALL YOU AND THE PHONE NUMBER YOU WOULD LIKE US TO USE:

GENERAL INFORMATION
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES? ☐ YES ☐ NO
DO YOU HAVE A RELIABLE MEANS OF TRANSPORTATION TO JOB ASSIGNMENTS? ☐ YES ☐ NO
HOW DID YOU LEARN ABOUT FIVE STARR?

☐ WALK-IN ☐ AD (PUBLICATION): ______________________ ☐ REFERRED BY: ___________________________

☐ FIVE STARR REPRESENTATIVE NAME:___________________________ TITLE:_____________________________
HAVE YOU EVER REGISTERED WITH OR BEEN EMPLOYED BY FIVE STARR BEFORE? ☐ YES ☐ NO
IF SO, PLEASE GIVE DATES AND FIVE STARR OFFICE:

TO BE COMPLETED BY PATIENT CARE APPLICANTS

HAS A LICENSE/CERTIFICATION EVER BEEN ISSUED IN ANOTHER STATE? ☐ YES ☐ NO
IF YES, PLEASE GIVE DETAILS:
DO YOU HAVE A CURRENT, VALID LICENSE/CERTIFICATION? ☐ YES ☐ NO
LICENSE/CERT. TYPE:_________________STATE:_________________LICENSE NO:_____________EXP.DATE:_____________
LICENSE/CERT. TYPE:________________ STATE:________________ LICENSE NO:_____________EXP. DATE:_____________
SPECIALTY/OTHER:___________________EXP.DATE:______________LICENSE NO:_____________EXP. DATE:_____________
CPR:_______________EXP. DATE :______________________ BLS:___________________ EXP. DATE:_____________________
ACLS:______________ EXP. DATE:______________________ OTHER:___________________ EXP.DATE:___________________
HAS YOUR PROFESSIONAL LICENSE, CERTIFICATE OR REGISTRATION EVER BEEN SUBJECT TO DISCIPLINARY
ACTION BY ANY STATE BOARD OR BODY, SUCH AS BY REPRIMAND, SUSPENSION, REVOCATION, CONSENT
ORDER, VOLUNTARY SURRENDER OR FINES? ☐ YES ☐ NO
ARE YOU CURRENTLY WORKING UNDER A CONSENT ORDER OR WITH A RESTRICTED LICENSE FROM ANY STATE
LICENSING BODY OR BOARD? ☐ YES ☐ NO
ARE YOU AWARE OF ANY PENDING COMPLAINTS OR INVESTIGATIONS AGAINST YOUR PROFESSIONAL LICENSE,
CERTIFICATE OR REGISTRATION IN ANY STATE TO THE BEST OF YOUR KNOWLEDGE? ☐ YES ☐ NO
*IF YES, PLEASE PROVIDE DETAILS ON A SEPARATE SHEET.
DATA TO BE COMPLETED BY PATIENT CARE APPLICANTS (CONT.)
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITIONFOR WHICH YOU ARE APPLYING, WITH
OR WITHOUT A REASONABLE ACCOMMODATION? ☐ YES ☐ NO
DO YOU HAVE PROFESSIONAL LIABILITY INSURANCE? ☐ YES ☐ NO
IF YES, GIVE CARRIER NAME:___________________________ POLICY NUMBER:____________________________
EXP. DATE: ______________________________
DO YOU HAVE COMPUTER SKILLS? ☐ YES ☐ NO TYPE OF SOFTWARE:_____________________
HAVE YOU COMPLETED A COURSE IN MEDICAL BILLING/CODING? ☐ YES ☐ NO
DATE: _______________________________
EMR EXPERIENCE? ☐ YES ☐ NO # OF YEARS:______________
WHICH EMR SOFTWARE? ☐ EPIC ☐ MCKESSON ☐ CERNER ☐ MEDITECH ☐ OTHER: _________________________
SUMMARIZE ANY SPECIAL TRAINING, SKILLS, LICENSES AND/OR CERTIFICATES THAT MAY QUALIFY YOU AS
BEING ABLE TO PERFORM JOB- RELATED FUNCTIONS IN THE POSITION FOR WHICH YOU ARE APPLYING:

WORK HISTORY
APPLICATIONS WILL NOT BE CONSIDERED UNLESS ALL INFORMATION IS COMPLETE, EVEN IF A RESUME IS PRESENTED.

PRESENT POSITION:
EMPLOYER: ________________________________________________
FROM TO TELEPHONE NUMBER: _______________________________________
STREET ADDRESS, CITY, STATE, ZIP:____________________________
MONTH YEAR MONTH YEAR
______________________________________________________________

POSITION SUPERVISOR’S EMAIL SUPERVISOR’S NAME AND TITLE MAY WE CONTACT?

☐ YES ☐ NO

DESCRIBE DUTIES AND SPECIALTY AREAS REASON FOR LEAVING:

# OF HOSPITAL BEDS (IF APPLICABLE)

PREVIOUS POSITION:
EMPLOYER: ________________________________________________
FROM TO TELEPHONE NUMBER: _______________________________________
STREET ADDRESS, CITY, STATE, ZIP:___________________________
MONTH YEAR MONTH YEAR
_____________________________________________________________

POSITION SUPERVISOR’S EMAIL SUPERVISOR’S NAME AND TITLE MAY WE CONTACT?

☐ YES ☐ NO

DESCRIBE DUTIES AND SPECIALTY AREAS REASON FOR LEAVING:

# OF HOSPITAL BEDS (IF APPLICABLE)

PREVIOUS POSITION:
EMPLOYER: ________________________________________
FROM TO TELEPHONE NUMBER: _______________________________
STREET ADDRESS, CITY, STATE, ZIP:____________________
MONTH YEAR MONTH YEAR
______________________________________________________

POSITION SUPERVISOR’S EMAIL SUPERVISOR’S NAME AND TITLE MAY WE CONTACT?

☐ YES ☐ NO

DESCRIBE DUTIES AND SPECIALTY AREAS REASON FOR LEAVING:

# OF HOSPITAL BEDS (IF APPLICABLE) LIST OTHER EMPLOYERS AND DATES OF EMPLOYMENT. ATTACH
A RESUME IF AVAILABLE.

PROFESSIONAL REFERENCES
LIST NAME AND TELEPHONE NUMBER OF THREE BUSINESS/WORK REFERENCES WHO ARE NOT RELATED TO
YOU. IF NOT APPLICABLE, LIST THREE SCHOOL REFERENCES WHO ARE NOT RELATED TO YOU.

NAME TELEPHONE NUMBER OF

YEARS KNOWN

EDUCATION AND TRAINING

HIGHEST COLLEGE POST GRADUATE
☐MASTERS ☐PHD
NO. OF
GRADE 1☐ 2☐ 3☐4☐ MAJOR YEARS DEGREE OBTAINED
COMPLETED
☐ 12 ☐ GED
COMPLETED
HIGH SCHOOL ADDRESS

VOCATIONAL/TECHNICAL ADDRESS

HOSPITAL OR NURSING SCHOOL ADDRESS

COLLEGE/UNIVERSITY BA/BS ADDRESS

MASTERS / PH.D. ADDRESS

OTHER EDUCATION OR SPECIAL TRAINING (INCLUDE MILITARY):

ACKNOWLEDGEMENT & AUTHORIZATION
I represent that the information provided in this employment application (and accompanying documents, if any) is true and
complete. I understand that any false information or significant omissions may disqualify me from any further consideration for
employment and may be justification for dismissal from employment if discovered at a later date. I agree to immediately notify
Five Starr Healthcare Staffing, LLC. if I should be convicted of any crime while my job application is pending.

I authorize investigation of all statements contained in this application and authorize any individual or entity to provide
information and opinion to Five Starr Healthcare Staffing, LLC as part of the investigation. I authorize Five Starr Healthcare
Staffing, LLC to disclose information contained in this application along with any information about me obtained through
investigations or during the course of the interview process. I release Five Starr Healthcare Staffing, LLC. and any individual,
or entity providing information to Five Starr, from any legal liability for any damages from the disclosure of this information.

I understand that if accused of wrongdoing while employed, I may be subject to probe by an outside agency.

I understand and agree that, if I am hired, my employment is “at-will” which means that it is for no definite period of time and
may be terminated by me or Five Starr at any time for any reason.

I understand that if I am hired, Five Starr Healthcare Staffing, LLC does not guarantee any specific number of hours or shifts
and I may or may not be assigned as determined by Five Starr. I understand and agree that I will not accept employment by
any Five Starr client where I have been assigned by Five Starr for a period of six (6) months following termination of my
employment with Five Starr Healthcare Staffing, LLC.

I understand that if I am hired, a client may decide not to utilize my services at any time and will inform Five Starr if this occurs.
That decision is made solely by the client. I understand and acknowledge that if this occurs, I may, or may not be assigned to
other clients. In the event I have any concerns regarding my assignment to a client, I will immediately bring my concerns to
Five Starr Healthcare Staffing, LLC’s attention.

I agree, if I am hired by Five Starr Healthcare Staffing, LLC, to keep my credentials and JOINT COMMISSION and OSHA
inservice requirements current, and to abide by the policies, procedures and supervision of the client to which I am assigned
and those of Five Starr Healthcare Staffing, LLC.

Acknowledged and agreed:

_____________________________

_____________________________ ________________________
Applicant Signature Date

(TO BE COMPLETED BY FIVE STARR REPRESENTATIVE ONLY)

On what date will employee be available for assignment?

Hours Associate available for assignment: ☐ 7a - 3p ☐ 3p -11p ☐11p – 7a ☐ 7a – 7p ☐ 7p – 7a ☐ Other__________

Days available for assignment: ☐ SAT ☐ SUN ☐ MON ☐ TUE ☐ WED ☐ THUR ☐ FRI
Any special requests:

Assignment Preferences: Comments/Area Preference:

Contracts-Local ☐ YES ☐ NO
Local Travel
Specialty Areas: 1st Choice 2nd Choice 3rd Choice

Five Starr Date_________________________

Representative______________________________________________________
 EMPLOYEMENT REFERENCE
Address: ______________________________________________________________________________________________

Attention: ______________________________________________________________________________________________

The person named below has applied for employment with Five Starr Healthcare Staffing, LLC and has listed you as a previous
employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information will be
kept CONFIDENTIAL

APPLICANT RELEASE

Applicant Last name First Name Middle Name Other

COMPANY/FACILITY:__________________________________
TITLE:___________________________________________
SOCIAL SECURITY NO:_______________________ DATES EMPLOYED: FROM_____________ TO ______________
PAY RATE: $ ____________________________________________

EMPLOYMENT REFERENCE RELEASE

I authorize the person or company completing this form to release all information (including opinion information) regarding my employment
with them. I hereby release and hold harmless any individual, or company which is providing this information, both factual and opinion to
Five Starr, and Five Starr Healthcare Staffing, LLC., its representatives and agents, from any legal liability for any damages that may
result from the disclosure of this information.

_____________________________ ______________________
APPLICANT SIGNATURE DATE
EMPLOYER RESPONSE
1. Do the employment dates above correspond with your records? ☐ Y E S ☐ N O If not, please correct dates.
Comments: _____________________________________________________________________________________

☐ YES ☐ NO
2. Is there anything in the individual’s work history that would pose a threat to patient safety?
Comments: _____________________________________________________________________________________

3. Was this person ever disciplined for work related conduct/incidents? ☐ YES ☐ NO
4. Would you rehire this employee? ☐ YES ☐ NO
1. Please check the POOR AVERAGE GOOD EXCELLENT
appropriate boxes in the ATTENDANCE
table to the right. PUNCTUALITY
DEPENDABILITY
2. Check here if the
QUALITY OF WORK
facility/institution/organiza
tion does not release any JOB KNOWLEDGE/SKILLS
information and confirms JUDGEMENT
only dates of employment ACCEPTS SUPERVISIONS
and title held APPEARANCE
ATTITUDE/COOPERATION

Reason for Leaving: _______________________________________________________________________________________________

Responsibilities and Duties: _________________________________________________________________________________________

Comments: ______________________________________________________________________________________________________

Signature: _________________________ Title:___________________________________ Phone #:______________________________

Institution: ______________________________________☐ Phone reference by: __________________________ Date: __________________

 EMPLOYEMENT REFERENCE
Address: ______________________________________________________________________________________________

Attention: _____________________________________________________________________________________________

The person named below has applied for employment with Five Starr Healthcare Staffing, LLC and has listed you as a previous
employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information will be
kept CONFIDENTIAL

APPLICANT RELEASE

Applicant Last name First Name Middle Name Other

COMPANY/FACILITY:__________________________________
TITLE:___________________________________________
SOCIAL SECURITY NO:_________________________ DATES EMPLOYED: FROM___________ TO ______________
PAY RATE: $ ____________________________________________

EMPLOYMENT REFERENCE RELEASE

I authorize the person or company completing this form to release all information (including opinion information) regarding my employment
with them. I hereby release and hold harmless any individual, or company which is providing this information, both factual and opinion to
Five Starr, and Five Starr Healthcare Staffing, LLC., its representatives and agents, from any legal liability for any damages that may
result from the disclosure of this information.

_____________________________ ______________________
APPLICANT SIGNATURE DATE

EMPLOYER RESPONSE
5. Do the employment dates above correspond with your records? ☐ Y E S ☐ N O If not, please correct dates.
Comments: _____________________________________________________________________________________

☐ YES ☐ NO
6. Is there anything in the individual’s work history that would pose a threat to patient safety?
Comments: _____________________________________________________________________________________

7. Was this person ever disciplined for work related conduct/incidents? ☐ YES ☐ NO
8. Would you rehire this employee? ☐ YES ☐ NO
1. Please check the POOR AVERAGE GOOD EXCELLENT
appropriate boxes in the ATTENDANCE
table to the right. PUNCTUALITY
DEPENDABILITY
2. Check here if the
QUALITY OF WORK
facility/institution/organiza
tion does not release any JOB KNOWLEDGE/SKILLS
information and confirms JUDGEMENT
only dates of employment ACCEPTS SUPERVISIONS
and title held APPEARANCE
ATTITUDE/COOPERATION

Reason for Leaving: _______________________________________________________________________________________________

Responsibilities and Duties: _________________________________________________________________________________________

Comments: ______________________________________________________________________________________________________

Signature: _________________________ Title:___________________________________ Phone #:______________________________

Institution: ______________________________________☐ Phone reference by: __________________________ Date: __________________

 OSHA Hepatitis B Form or Declination
(Maintain form in Employee Confidential File)

Print Name: ____________________________________________________

I understand that due to my actual or potential occupational exposure to blood or other potentially infectious
materials (OPIM), I may be at risk of acquiring hepatitis B (HBV) infection. You may obtain the Hepatitis B
vaccination series and post-exposure evaluation through Five Starr Healthcare Staffing, LLC referral at no
cost to you.
Hepatitis B vaccination is recommended unless:
1. Documentation of prior vaccination and post-vaccination titer is provided to Five Starr.
2. Medical evaluation identifies vaccination is contraindicated (please provide the documentation). In
such circumstances, Five Starr may not be able to place you at client facilities that require hepatitis B
vaccination of all staff.

I declare the following:

☐ I have already received the Hepatitis B Vaccination (a series of 3 shots, indicate month and year) on
the following dates #1 , #2 , and #3 .

****Please provide documentation confirming the immunization series and the post vaccine titer laboratory
results page.

☐ I want to receive the Hepatitis B Vaccination. If you choose to receive the vaccine (a series of 3
shots), Five Starr Healthcare Staffing, LLC will refer you to a proper source so that you may receive the vaccine
at no charge to yourself.

Employee Signature: _____________________________________

Date:

*****IF YOU DECLINE VACCINATION***** YOU MUST READ THIS STATEMENT AND SIGN BELOW

☐ I Decline Hepatitis B Vaccination

I do not want to receive the Hepatitis B Vaccination; I decline to be vaccinated against Hepatitis B.
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be
at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with
hepatitis B vaccine, at no charge to myself.
However, I decline vaccination at this time. I understand that by declining this vaccine, I continue to be at risk
of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood
or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, Five Starr
Healthcare Staffing, LLC will refer me to a proper source so that I can receive the vaccination series at no
charge to myself.
Employee Signature: _____________________________________
Date:
 Policy Acknowledgment

Safety, Accidents/Injuries, and Substance Abuse

Please read the following Five Starr Healthcare Staffing, LLC policy statements and sign
the acknowledgment at the bottom of the page.

1. I understand Five Starr Healthcare Staffing, LLC takes its responsibility as my employer very seriously
and that it has gone to great expense to provide a safe work environment. In the event that I am
injured on the job, Five Starr Healthcare Staffing, LLC will deal promptly with legitimate claims and
injuries and has workers compensation insurance that will pay medical expenses and wages. I also
understand that Five Starr Healthcare Staffing, LLC has extensive experience investigating claims and
will fight fraudulent type claims with all available resources.

2. If I sustain an injury on the job, I will inform the client supervisor and Five Starr Healthcare Staffing,
LLC after the accident. Five Starr Healthcare Staffing, LLC will coordinate with the insurance carrier
and myself the proper procedure for treatment and reporting the accident.

3. Five Starr Healthcare Staffing, LLC has a “ZERO TOLERANCE DRUG POLICY” and I have signed a
consent form to submit to drug testing. I understand that my failure to comply with this agreement will
be grounds for my immediate termination.

4. I understand and will comply with Five Starr Healthcare Staffing, LLC safety rules and hazardous
communications program explained to me in the company’s orientation.

5. I have read and fully understand the above statements regarding Five Starr Healthcare Staffing, LLC
policies and procedures and agree to the same. I understand that failure to comply with these policies
and procedures could lead to my termination and may jeopardize my insurance benefits.

ACKNOWLEDGMENT
My signature below acknowledges that I have read and understand the Five Starr Healthcare Staffing,
LLC Safety, Accidents/Injuries, and Substance Abuse Policy

_______________________________ __________________________
Employee Signature Date

_______________________________ __________________________
Five Starr Healthcare Staffing, LLC
Representative Signature Date
HIPAA ACKNOWLEDGEMENT OF CONFIDENTIALITY OF PATIENT HEALTH
CARE INFORMATION
I acknowledge the confidentiality of patient health care information (“Confidential Patient Information”) that
I receive or have access to in the course of providing patient care services at healthcare institutions at
which I am assigned through Five Starr Healthcare Staffing, LLC.
I shall maintain the confidentiality of Confidential Patient Information, and in doing so, shall comply with
all applicable state and federal laws and regulations, including, without limitation, the privacy provisions
under the Health Insurance Portability and Accountability Act of 1996 (”HIPAA”) and the policies and
procedure of each healthcare institution where I am assigned.
My agreement to maintain the confidentiality of Confidential Patient Information shall survive the
termination of my employment with Five Starr Healthcare Staffing, LLC. and the conclusion of any
assignment at a healthcare institution through the same.

_______________________________
Printed Name

_______________________________
Signature

________________________________
Date
 Policies and Procedures

Policy Title: Hand Hygiene, Hand washing and Policy Number: 509
Hand Sanitizer Use for Healthcare Workers Effective Date: January 1, 2019
(based on CDC Guidelines) Revision Date: March 1, 2020
Approved By: Committee

Purpose
Effective hand hygiene reduces the incidence of healthcare-associated infections.
Policy
A. All Five Starr Healthcare Staffing, LLC will comply with current Centers for Disease Control and
Prevention (CDC) hand hygiene guidelines.
B. Hand Hygiene means cleaning hands by using either handwashing (washing hands with soap
and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol- based hand sanitizer
including foam or gel).
C. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs
on the hands of healthcare providers according to the CDC.
D. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical
situations.
E. Wash your hands with soap and water whenever they are visibly dirty, before eating, and
after using the restroom.

Procedure
Indications for Hand Hygiene: Multiple opportunities for hand hygiene may occur during a single care
episode. You must also follow all client-specific protocols in place. If you do not understand them, as
your work-site supervisor.

A. The following are the clinical indications for hand hygiene

1. Immediately before touching a patient

2. When hands are visibly soiled
3. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive
medical devices
4. After caring for a person with known or suspected infectious diarrhea
5. Before moving from work on a soiled body site to a clean body site on the same patient
6. After known or suspected exposures
7. After touching a patient or the patient’s immediate environment
8. After contact with blood, body fluids or contaminated surfaces
9. Immediately after glove removal
B. Wash Hands with Soap and Water

1. When hands are visibly soiled

2. After caring for a person with known or suspected infectious diarrhea
3. After known or suspected exposure to spores
(e.g., B. Anthracis, C difficile outbreaks)

C. How to Use Alcohol-based Hand Sanitizer

1. Put product on hands and rub hands together

2. Cover all surfaces until hands feel dry
3. This should take around 20 seconds

D. How to wash your hands

The CDC Guideline for Hand Hygiene in Healthcare Settings pdf icon [PDF – 1.3 MB] recommends:

1. When cleaning your hands with soap and water, wet your hands first with water, apply
the amount of product recommended by the manufacturer to your hands, and rub your
hands together vigorously for at least 20 seconds, covering all surfaces of the hands and
fingers.
2. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the
faucet.
3. Avoid using hot water, to prevent drying of skin.
4. Follow all special procedures in place in place at work-sites.

E. Gloves and Hand Hygiene

1. Wear gloves, according to Standard Precautions, when it can be reasonably anticipated

that contact with blood or other potentially infectious materials, mucous membranes,
non-intact skin, potentially contaminated skin or contaminated equipment could occur.
2. Gloves are not a substitute for hand hygiene.
3. If your task requires gloves, perform hand hygiene prior to donning gloves, before
touching the patient or the patient environment.
4. Perform hand hygiene immediately after removing gloves.
5. Change gloves and perform hand hygiene during patient care, if

a. gloves become damaged,

b. gloves become visibly soiled with blood or body fluids following a task,
c. Moving from work on a soiled body site to a clean body site on the same patient or
if another clinical indication for hand hygiene occurs.

6. Never wear the same pair of gloves in the care of more than one patient. Carefully remove
gloves to prevent hand contamination.
F. Surgical Hand Washing

The following are CDC guidelines. Follow all client specific procedures or special procedure protocols.
1. Remove rings, watches, and bracelets before beginning the surgical hand scrub
2. Remove debris from underneath fingernails using a nail cleaner under running water
3. Performing surgical hand antisepsis using either an antimicrobial soap or an alcohol-based
hand sanitizer with persistent activity is recommended before donning sterile gloves when
performing surgical procedures
4. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and
forearms for the length of time recommended by the manufacturer, usually 2–6 minutes
5. Long scrub times (e.g., 10 minutes) are not necessary
6. When using an alcohol-based surgical hand-scrub product with persistent activity, follow
the manufacturer’s instructions
7. Before applying the alcohol solution, prewash hands and forearms with a non-
antimicrobial soap and dry hands and forearms completely
8. After application of the alcohol-based product as recommended, allow hands and
forearms to dry thoroughly before donning sterile gloves
9. Double gloving is advised during invasive procedures, such as surgery, that pose an
increased risk of blood exposure
10. Bacteria on the hands of surgeons can cause wound infections if introduced into the
operative field during surgery
11. Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with a
non-antimicrobial soap
12. Bacterial growth is slowed after preoperative scrubbing with an antiseptic agent
13. Reducing resident skin flora on the hands of the surgical team for the duration of a
procedure reduces the risk of bacteria being released into the surgical field if gloves
become punctured or torn during surgery

G. Lotions

1. Lotions and creams can prevent and decrease skin dryness that happens
from cleaning your hands
2. Use only hand lotions approved by your healthcare facility because they won’t
interfere with hand sanitizing products

H. Fingernail and Jewelry

1. Germs can live under artificial fingernails both before and after using an alcohol- based
hand sanitizer and hand washing
2. It is recommended that healthcare providers do not wear artificial fingernails or
extensions when having direct contact with patients at high risk (e.g., those in intensive-
care units or operating rooms)
3. Keep natural nail tips less than ¼ inch long
4. Some studies have shown that skin underneath rings contains more germs than
comparable areas of skin on fingers without rings
5. Further studies are needed to determine if wearing rings results in an increased spread
of potentially deadly germs
References

To access the CDC’s hand hygiene guidelines in their entirety, see the CDC website at:
https://www.cdc.gov/handhygiene/providers/index.html

Acknowledgment:

By signing below, I acknowledge that I have read and understand this policy on hand hygiene, hand
washing and hand sanitizing.

__________________________
Signature

__________________________
Date
 INFLUENZA (FLU) VACCINATION HISTORY OR DECLINATION
FIVE STARR HEALTHCARE STAFFING LLC OFFICE INSTRUCTIONS: This record is to be
maintained in the Employee’s Medical File
The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC)
recommend healthcare workers with direct patient care duties receive an annual influenza vaccine.
Transmission of influenza from health care workers to patients and from patients to healthcare workers
has been documented.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that can result in hospitalization and death.
• Influenza vaccination is recommended for all healthcare workers with direct patient contact to
prevent influenza disease and its complications.
• If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms appear.
My shedding the virus can spread influenza to patients.
• I understand that the strains of virus that cause influenza infection can change almost every
year. This is the reason why a different influenza vaccine is recommended annually.
• I cannot get influenza disease from receiving an influenza vaccine.
• The consequences of my refusing to be vaccinated could potentially endanger my health and
the health of my patients, co-workers, and family.
• If I decline Flu vaccination, I may be required to wear a mask during flu season.

I acknowledge the following by my signature,

• I have been informed by Five Starr Healthcare Staffing, LLC, of the facilities at which I can
receive the influenza vaccine. Influenza vaccination may be available at local clinics, local
pharmacies (e.g., CVS, Rite Aid), public health departments, occupational health clinics, local
hospital occupational health clinics, and physician offices.
• I will report to Five Starr Healthcare Staffing, LLC in a timely manner, the name of the facility
and date I received the vaccination which is to be documented on the Influenza Vaccination
Documentation Form or acceptable alternative provided by the vaccine administering facility.
Vaccination is annual and I will keep these records current with my employer.

EMPLOYEE SIGNATURE__________________________ Date: ______________________________

DECLINATION STATEMENT

I certify by my signature below that I understand that due to my occupational exposure to potentially
infected materials and patients that I may be at risk for acquiring influenza. I have been provided with
information where to obtain influenza vaccination, however, I decline vaccination at this time. I
understand that by declining this vaccine, I continue to be at risk of acquiring Influenza. I also
understand that some facilities may require flu vaccination, and that if this is the case, I may not be
eligible to be staffed in such facilities (like hospitals, nursing homes and assisted living facilities)
without meeting their employee health requirements, including flu vaccination. If I decline Flu
vaccination, I may be required to wear a mask during flu season.

EMPLOYEE SIGNATURE__________________________ Date: ______________________________

A) EMPLOYEE SUBSTANCE ABUSE POLICY B) DRUG SCREEN AUTHORIZATION
C) RELEASE OF CRIMINAL RECORDS

A) EMPLOYEE SUBSTANCE ABUSE POLICY

It is the purpose of Five Starr Healthcare Staffing, LLC to help provide a drug free environment for
our clients and our employees. With this goal and because of the serious drug abuse problem in
today’s workplace, we are establishing the following policy for existing and future employees of
Five Starr Healthcare Staffing, LLC.

Five Starr Healthcare Staffing, LLC explicitly prohibits:

The use, possession, solicitation or sale of narcotics or other illegal drugs, alcohol, or
prescription medications without a prescription on company or customer premises or while
performing an assignment.

Being impaired or under the influence or legal or illegal drugs or alcohol off the company or
customer premises that adversely affects employee’s work performance, his or her own or
others’ safety at the workplace, or the employee’s reputation.

Five Starr Healthcare Staffing, LLC may drug test using S.A.M.H.S.A. standards by four methods:
Pre-employment: As may be required by client.
Randomly: A random selection of some employees for testing will be done announced
Post Accident: Any employee involved in an accident/injury while performing services
for our Company or client that results in property damage or bodily
injury requiring medical treatment will be required to submit to a
substance abuse screening.
For Cause: When it is the Company’s belief that a drug problem exists (such as
evidence of drugs, accidents, injuries in the work-place, fights, or other
behavioral symptoms or signs of drug abuse, negative performance
patterns, excessive absenteeism or tardiness) for-cause testing will be
utilized.
Employees who refuse to submit to drug testing, test positive, or admit to substance abuse will
be subject to termination and other appropriate actions as mandated by applicable state law.

Also, employees of Five Starr Healthcare Staffing, LLC who test positive or admit to substance
abuse may be referred to local public agencies that provide rehabilitation and counseling
services.

The results of all drug testing will be treated confidentially except as otherwise state herein.

EMPLOYEE SIGNATURE__________________________ Date: ______________________________

B) DRUG SCREEN AUTHORIZATION AND CONSENT (page 2 of 2)

I hereby authorize and give full permission to have Five Starr Healthcare Staffing, LLC and/or
their medical company physician send a specimen or my urine and/or blood to a laboratory for
screening test using S.A.M.H.S.A. standards for the presence of illegal drugs, alcohol, or
prescription medication taken without a prescription.

I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any
alleged harm to me or interfering with my obtaining a job or continuing employment due to not
submitting to the tests or as a result of report of the test. This includes, but is not limited to,
possible clerical or laboratory error.

This policy and authorization has been explained to me in a language I understand and told if I
have any questions they will be answered about the test. I understand this is a legal and binding
document which is binding because Five Starr Healthcare Staffing, LLC. is sending me for the
examinations and paying for it.

I UNDERSTAND FIVE STARR HEALTHCARE STAFFING, LLC. WILL REQUIRE DRUG

SCREEN TESTING WHENEVER AN ON THE JOB ACCIDENT OR INJURY IS REPORTED IN
ACCODANDANCE WITH FIVE STARR HEALTHCARE STAFFING LLC’S INJURY POLICY
AND THIS AUTHORIZATION AND CONSENT. MY REFUSAL TO SUBMIT TO DRUG TESTING
WILL BE GROUNDS FOR TERMINATION.

Signature: _____________________________ Date of Release: __________________________

Print Name: ____________________________________________________________________________

Social Security Number: __________________________________________________________________

Driver’s License Number and Date: _________________________________________________________

TITLE: PROFESSIONAL REGISTERED NURSE, ADULT MEDICAL SURGICAL

REPORTS TO: FRANCHISEE, BRANCH MANAGER OR DESIGNEE AND APPROPRIATE CLIENT

REPRESENTATIVE

JOB SUMMARY
The ADULT MEDICAL SURGICAL REGISTERED NURSE (RN) is a healthcare provider who through
education and experience possesses a distinct body of knowledge and skills relative to the care of the adult
patient across the lifespan who is experiencing general medical conditions or general surgical interventions.
He/she applies general nursing knowledge in assessing, implementing, and evaluating patient response to
general and specific conditions, general therapies and interventions. He/she initiates nursing care, health
teaching, and health counseling that supports life and restores well-being. Nursing care is performed in
accordance with the nurse practice act and under the direction and supervision of the appropriate client
representative(s) on the assigned Adult Medical Surgical Unit.

EDUCATION
Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing.
LICENSURE
Current and unrestricted RN nursing license in the state of practice.

EXPERIENCE
One year of experience as an RN in an Adult Medical Surgical Unit in the last three years.

CREDENTIALS
Current CPR at least to the BLS level; and other health and screening tests as required by specific facilities
and/or regulatory agencies.

ENVIRONMENTAL WORKING CONDITIONS

Various client facility settings; possible exposure to blood, bodily fluids, and other potentially infectious materials.

REPRESENTATIVE DUTIES AND RESPONSIBILITIES

• Complies with Five Starr Healthcare Staffing LLC policies/procedures.
• Complies with client facility nursing policies/procedures.
• Conducts individualized patient assessment, prioritizing collection of data based on individual needs
and condition.
• Conducts ongoing nursing assessment as dictated by the patient's condition and in accordance with
client facility's protocols.
• Collaborates with other team members in the development, implementation, and evaluation of an
individualized plan of care.
• Performs appropriate treatments and therapies as ordered by physician in an appropriate and timely
fashion.
• Provides individualized patient and family teaching.
• Documents patient assessments, findings, and psychosocial responses to nursing interventions
• Initiates emergency measures according to adult and client resuscitation protocols.
• Maintains confidentiality related to patient, family, client facility and staff in accordance with the Health
Insurance Portability and Accountability Act (HIPAA).
• Provides patient care in a non-judgmental, non-discriminatory manner that considers cultural diversity and age
appropriateness so that autonomy, rights, and dignity are preserved.
• Advocates patient rights with respect to advance directives and organ donation.
• Reports patient condition to appropriate personnel during each shift, as needed based on individualized
patient assessment.
• Maintains competency by participating in continuing education programs and meets state specific
requirements.
• Complies with accepted ethical conduct and professional Standards of Nursing Practice as set forth by the
American Nurses Association or equivalent national organization.
• Demonstrates ability to delegate effectively and appropriately.

RN Signature: _____________________________

Date: __________________________

This Job Summary is meant to function as a general guideline and is not all inclusive.
 INFLUENZA (FLU) VACCINATION HISTORY OR DECLINATION

Five Starr Healthcare Staffing, LLC OFFICE INSTRUCTIONS: This record is to be maintained in the
Employee’s Medical File
The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC)
recommend healthcare workers with direct patient care duties receive an annual influenza vaccine.
Transmission of influenza from health care workers to patients and from patients to healthcare workers
has been documented.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that can result in hospitalization and death.
• Influenza vaccination is recommended for all healthcare workers with direct patient contact
to prevent influenza disease and its complications.
• If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms
appear. My shedding the virus can spread influenza to patients.
• I understand that the strains of virus that cause influenza infection can change almost every
year. This is the reason why a different influenza vaccine is recommended annually.
• I cannot get influenza disease from receiving an influenza vaccine.
• The consequences of my refusing to be vaccinated could potentially endanger my health
and the health of my patients, co-workers, and family.
• If I decline Flu vaccination, I may be required to wear a mask during flu season.

I acknowledge the following by my signature,

• I have been informed by Five Starr Healthcare Staffing, LLC, of the facilities at which I can
receive the influenza vaccine. Influenza vaccination may be available at local clinics, local
pharmacies (e.g., CVS, Rite Aid), public health departments, occupational health clinics,
local hospital occupational health clinics, and physician offices.
• I will report to Five Starr in a timely manner, the name of the facility and date I received
the vaccination which is to be documented on the Influenza Vaccination Documentation
Form or acceptable alternative provided by the vaccine administering facility. Vaccination
is annual and I will keep these records current with my employer.

EMPLOYEE SIGNATURE:________________________ DATE: __________________________

DECLINATION STATEMENT:
I certify by my signature below that I understand that due to my occupational exposure to potentially
infected materials and patients that I may be at risk for acquiring influenza. I have been provided with
information where to obtain influenza vaccination, however, I decline vaccination at this time. I
understand that by declining this vaccine, I continue to be at risk of acquiring Influenza. I also
understand that some facilities may require flu vaccination, and that if this is the case, I may not be
eligible to be staffed in such facilities (like hospitals, nursing homes and assisted living facilities) without
meeting their employee health requirements, including flu vaccination. If I decline Flu vaccination, I may
be required to wear a mask during flu season.
EMPLOYEE SIGNATURE:________________________ DATE: __________________________
 COVID-19 VACCINATION FORM OR DECLINATION STATEMENT

Employee Statement: Check one statement below next to your choice.

☐ I have received the COVID-19 vaccination and will provide proof of vaccination records to Five
Starr Healthcare Staffing, LLC. Please provide the vaccination printout from the medical
provider.

☐ I decline the COVID-19 Vaccine. I understand that I may continue to be exposed to the COVID-19
virus due to my occupational exposure to patients that may be infected or through handling of
potentially infectious materials. I further understand that clients may require the use of a mask for
those that refuse to be vaccinated. Some clients may require proof of COVID vaccination to work in
their facilities.

______________________________________
Printed Name

______________________________________
Signature

______________________________________
Date