Employment & Health Requirements Checklist

Please note if the traveler accepts this offer, the agency must provide proof of the following Employment
and Health Requirements no later than five (5) business days prior to start date of the assignment.

ADENA HEALTH SYSTEM HAS MANDATED ALL EMPLOYEES, INCLUDING CONTRACT STAFF, BE FULLY
VACCINATED AGAINST COVID-19 PER CMS RULE. FIRST DOSE MUST BE RECEIVED BY DECEMBER 5, 2021;
SECOND DOSE (IF APPLICABLE) MUST BE RECEIVED BY JANUARY 4, 2022.

Please upload documents as individual PDF files to www.medefis.com to include providing dates in
appropriate fields.

• Online verification of license to include expiration date and any disciplinary actions - within
30 days of start
• BLS - copy of both sides of signed card - must be American Heart Association
• All Copies of Nursing/Allied Certifications, i.e.: ACLS, TNCC, NBSTSA, ARRT
• MMR - 2 vaccine doses or positive titers
• Varicella - 2 vaccine doses or positive titer
• Hepatitis B - vaccine series, titer, or declination
• Flu Vaccination - required October 1st through March 31st - must be from THIS flu
season - declinations accepted for documented medical/religious reasons
• Due to CDC guidelines, TB tests must be within 3 weeks of start date
o Two TSTs (Tuburculin Skin Test) or One blood test: QuantiFERON/T-Spot/TB Gold with negative
results within last 21 days
o Past positive result will require clear chest x-ray within 5 years and TB Questionnaire
within one year of start date
o Newly positive TST (never tested prior) also recommended to refer for treatment
• Physical or General Statement of Health - within 12 months of start date
• 10 Panel Drug Screen - within 30 days of start date
• Proof of vaccination against COVID-19
• Resume
• Education Verification - 3rd party verification
• AHS Contracted Employee Packet
• Clinical Competency Exam - within 12 months of start date - MUST pertain to Modality
• Skills Checklist
• Headshot for Badge Photo – it should be a professional photo from the shoulders up, taken
against a blank, neutral background
• AHS Network Account Request Form
• Statewide Criminal Background check - within 30 days of start date - must go back 7
years for all states lived to include all aliases
• Social Security Address Check - within 30 days of start date
• GSA - within 30 days of start date
• OIG - within 30 days of start date