Healthcare Professional Responsibilities Agreement

Employee Name: _________________________________________________________

(Last Name, First Name)

I attest that I am not currently excluded, suspended, debarred or otherwise ineligible to

participate in Federal health care programs (i.e. Medicare, Medicaid, etc). I further attest that I
have not been convicted of a criminal offense related to the provision of health care items or
services, nor are there any judgments pending against me that will result in my being excluded,
debarred or otherwise declared an “ineligible person”.

I agree to immediately notify HealthTrust Workforce Solutions of any event that results in my
being classified as an “ineligible person”.

I understand that if HealthTrust Workforce Solutions learns that I am on a state (if

applicable) or federal exclusion list (GSA list or OIG Sanction report), I will be terminated
immediately for misconduct and will not be eligible for rehire at any HCA facility or
affiliated.
Licensed Individuals: I understand that as a healthcare professional, I am responsible for
maintaining an active professional license while working for HealthTrust Workforce Solutions. I
attest that there are no legal proceedings or inquiries in process that could result in
suspension or revocation of my license. I also agree to immediately inform HealthTrust
Workforce Solutions in the event of any inquiry or legal proceeding that could result in
suspension or revocation of my license. I understand that if I fail to notify HealthTrust
Workforce Solutions and the company discovers that I worked with an expired, suspended,
and revoked license, I will be subject to disciplinary action up to and including termination.

Signature: ______________________________________________________________

Printed Name: __________________________________________________________

Date: ____________________________
DocuSign Envelope ID: 86736159-6C8D-405C-9FC7-288A63605172

ŵĞƌŐĞŶĐLJŽŶƚĂĐƚ/ŶĨŽƌŵĂƚŝŽŶ

ŵƉůŽLJĞĞEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĂƚĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

/ŶĂƐĞŽĨŵĞƌŐĞŶĐLJŽŶƚĂĐƚ

EĂŵĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞůĂƚŝŽŶƐŚŝƉ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺWŚŽŶĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

EĂŵĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞůĂƚŝŽŶƐŚŝƉ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺWŚŽŶĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

^ŝŐŶĂƚƵƌĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

‹+HDOWK7UXVW:RUNIRUFH6ROXWLRQV$OOULJKWVUHVHUYHG
 SCHEDULE II TO SUPPLEMENTAL STAFFING
UTILIZATION POLICIES AND PROCEDURES

TB Questionnaire

EMPLOYEE NAME:

COMPANY NAME: DATE:

STEP I
DATE OF LAST PPD: RESULTS OF LAST PPD IN MM:

Please read and put a checkmark in the correct Yes/No space if you are experiencing
any of the following symptoms or if any of the following apply to you:

YES NO
1. Unexplained loss of weight (>10% of body weight)………………..
2. Night sweats……………………………………………………………
3. Fever lasting several weeks………………………………………….
4. Frequent coughing in the absence of a cold or flu…………………
5. Coughing blood-streaked sputum……………………………………
6. Unusual tiredness or weakness lasting weeks……………………..
7. Pain in chest when taking a breath…………………………………..
8. Have you been recently diagnosed with diabetes, silicosis, HIV,
renal disease or liver disease?.........................................................
9. Have you been recently exposed to a family member or others
with active TB?................................................................................

If you checked YES to any of the above questions, are you currently treating with a
physician?: YES NO

IF YOU DEVELOP ANY OF THE SYMPTOMS LISTED ABOVE, PLEASE CONTACT

YOUR PHYSICIAN AND AGENCY IMMEDIATELY. A CHEST X-RAY MAY BE
N E E D E D PRIOR TO WORKING AGAIN.

STEP II
If you have had a positive/sensitive PPD and are no longer required to have an
annual chest x-ray, the following is to be completed annually and maintained in the
personnel file. However, you must have the results of at least one x-ray on file.

DATE OF LAST X-RAY:

SIGNATURE DATE
Revised 12.09.2019

© HealthTrust Workforce Solutions. All rights reserved.

 HEPATITIS B VACCINE OR TITER DECLINATION

I understand that due to my occupational exposure to blood or other potentially infectious

materials, I may be at risk of acquiring Hepatitis B (HBV) infection. I have been given the
opportunity to be vaccinated with the Hepatitis B vaccine at no cost to myself. However, at this
moment I decline the Hepatitis B vaccine.

I understand that by declining this, 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 would like to be vaccinated with this vaccine, I may receive this at no
additional charge.

I want the vaccination for Hepatitis B.

I have already been vaccinated for Hepatitis B.

SIGNATURE Employee DATE (MM/DD/YYYY)

Job Description: RN Labor and Delivery
Labor and Delivery nurses are responsible for caring for women admitted into the hospital who
are in labor. This includes women who have normal and abnormal pregnancies. They must
provide information, and guidance to the mother and her family by educating them on the
birthing process and post-partum mother-baby care. They must provide clinical care using labor
and delivery nursing skills and a generally pleasant demeanor.

Requirements
 Must have an associates or bachelor’s degree in nursing
 Must be a licensed Registered Nurse
 Must have excellent observation and assessment skills
 Must have excellent teaching and communication skills
 Must have knowledge of common illnesses, diseases, or injuries for women during the
birthing process and immediately after the birthing process
 Must have knowledge of recovery requirements for women who developed illnesses or
injuries during and immediately after the birthing process
 Must be able to perform tests on newly born infants
 Must be able to develop, plan, implement, evaluate, document, and manage nursing
care for women and infants during and immediately after the birthing process
 Must be able to monitor fetal heartbeat during the birthing process
 Must be able to monitor length and strength of contractions during the birthing process
 Must be able to educate new mothers and families on infant care to improve or maintain
their and the baby’s health immediately after birth including how to monitor the baby’s
feeding, bathing techniques, sleeping schedule, proper breastfeeding techniques, etc.
 Must hold a current Basic Life Support Certification
 Must hold a current Neonatal Resuscitation Program Certification
 Must have completed a fetal monitoring certificate
 Must have a general knowledge of HIPAA rules and regulations
 Must have a basic knowledge of RN Pharmacology

Signature: _____________________________ Date: _______________________________

 Compact Licensure – Declaration of Residency- Compact License Information
My License is a Compact License

My License is not a Compact License

Name on professional license:

Address on Driver's License:

Declared State of Permanent Residency:

List of eNLC and NLC States: https://www.ncsbn.org/ListofMemberStatesandDates012518.pdf

I understand that if I declare my state of residency to be different than my Compact license state, I will
notify employer and HWS immediately. I understand I have only 30 days to obtain a new license in the
state where practicing and failure to do so will result in practicing with an invalid license and reportable
to all involved State Boards of Nursing.

I understand that the following actions may require me to obtain a new compact license:
ͻ obtain a driver’s license in a state other than my declared state of permanent residency
ͻ obtain a voters registration in a state other than my declared state of permanent residency
ͻ file federal income taxes in a state other than my declared state of permanent residency

Date:

Employee signature:

*Supporting Documentation: Driver’s License copy, the address must match state of
permanent residency declared above. If any other document is submitted to prove
permanent residency it must be approved by Governance.
Please note: This completed form and supporting documents must be resubmitted upon license
renewal, change of permanent residency, transfer, or upon request.

https://www.ncsbn.org/nurse-licensure-compact.htm
https://www.ncsbn.org/enhanced-nlc-implementation.htm 05/23/2018
 USP Chapter 800 Hazardous Drug Risk Acknowledgement

I understand working with or near hazardous drugs in the healthcare setting may For online training on this
cause skin rashes, infertility, miscarriage, birth defects, and possibly leukemia or topic, please scan the
other cancers. appropriate code with your
smartphone camera.
I acknowledge that my facility maintains detailed standard operating procedures
(SOPs) on the proper storage, handling, transport and disposal of hazardous drugs. For Clinicians:
My facility has put in place a variety of administrative, engineering and work practice
controls to reduce the risk of occupational exposure to hazardous drugs.
I understand the facility SOPs will be reviewed and /or amended on an annual basis
and the SOPs reflect information, standards, and regulations from relevant local,
state and federal regulatory bodies as well as practice standards from professional
associations.
Training was made available to me that included information applicable to
hazardous medications.
I agree to abide and follow the SOPs established by my facility and will discuss any For Non-Clinicians:
questions or concerns that I may have during work activities with my immediate
supervisor or pharmacy management.
I acknowledge that failure to follow the established SOPs may put me at risk of
exposure to hazardous substances which can lead to acute effects such as skin
rashes, chronic effects, including adverse reproductive events such as fertility,
miscarriage, or birth defects; and possibly the development of cancer.
☐ I acknowledge I have read and understood the contents of this attestation.

___________________________________________________ _______________________
Printed Name Date

___________________________________________________
Signature