HUMAN RESOURCES

CONTINGENT WORKER PACKET – CLINICAL

PERSONAL INFORMATION AND ACKNOWLEDGEMENTS First Name Middle Name Last Name

Address

City State Zip Code

Email Phone Number Date of Birth

Emergency Contact Emergency Contact’s Phone Number

Contract Company Name Company Contact

Company Contact’s Email Address Company Contact’s Phone Number

Position

Training Exam Version: Score:

Initialed Satisfactory Background Investigation Report Attestation Acknowledgement

On behalf of the company listed above, I acknowledge and attest that we own and have in our possession a background investigation report on the individual identified above. Such background investigation is satisfactory in that it: • Does not reveal any criminal conviction that has not been disclosed to OU Medicine, Inc.; • Confirms the individual is not listed as a violent crime or sexual offender; • Confirms the individual is not on the GSA or OIG exclusion lists; • Confirms this individual is not on the U.S. Treasury Department’s Office of Foreign Assets Control list of Specially Designation Nationals; and I further attest that the background investigation report does not include any information about prior or pending investigations, reviews, sanctions or peer review proceedings; or limitations of any licensure, certification or registration. This attestation is provided in lieu of providing a copy of the background investigation report.

Revised 09-2020 1 Initialed Application Attestation Acknowledgement

On behalf of the company listed above, I acknowledge and attest that we own and have in our possession an application submitted on behalf of the individual identified above, if applicable. The application in our possession includes work and education history. If requested, the application will be provided to OU Medicine, Inc.

Initialed Performance Evaluation Attestation Acknowledgement

On behalf of the company listed above, I acknowledge and attest that the individual identified above maintains and meets the annual performance requirements of the position with OU Medicine, Inc. If requested, the copies of performance evaluations will be provided to OU Medicine, Inc.

Initialed Drug Test Attestation Acknowledgement

On behalf of the company listed above, I acknowledge and attest that we own and have in our possession a satisfactory 10 panel drug test result on the individual identified above. The drug test results includes all of the following Amphetamines, Cocaine, Marijuana, Opiates (to include Synthetic Opiates), Propoxyphene, Benzodiazepines, Methaqualone, Methadone, Phencyclidine, and Barbiturates. If requested, the satisfactory drug test results will be provided to OU Medicine, Inc. Initialed Job Description Attestation Acknowledgement On behalf of the company listed above, I acknowledge and attest that we own and have in our possession a signed copy of a job description submitted on behalf of the individual identified above. The signed job description on file includes minimum qualifications, required competencies, and physical essential functions for the contracted position. If requested, the signed copy of the job description will be provided to OU Medicine, Inc. Initialed Licensure and Certification Attestation Acknowledgement

On behalf of the company listed above, I acknowledge and attest that we own and have in our possession active Primary Source Verification of any legally-required or hospital-required licensure, registration, and/or certification submitted on behalf of the individual identified above. Verifications will be conducted initially, when the credential expires, and upon renewal. Actions are taken to ensure that no one works without a legally-required or hospital-required credential. Upon each Primary Source Verification, a copy will be remitted to [email protected]. Company Agent Acknowledgement

I hereby attest that the individual sent to work in or on the premises of OU Medicine, Inc. is legally permitted to work in United States. I also acknowledge and agree to an annual compliance audit by the employer of five percent (5%) or a minimum of thirty (30) such background investigation files as authorized by the subjects under the Fair Credit Reporting Act (FCRA). Contract Company will document and verify worked hours of the above individual as OU Medicine, Inc. may also request documentation to verify hours worked. Contract Company acknowledges that individuals who work over 160 hours in a calendar year are required to complete trainings per OUM Policy HR.083. Also, the aforementioned Contract Company agrees to defend, indemnify, and hold OU Medicine, Inc. harmless in the event of any claim made against OU Medicine, Inc. related to any alleged failure of Contract Company to comply with its warranties, representations, and certifications. Signature Date

Revised 09-2020 2 PACCT: People | Accountability | Collaboration | Compassion | Transparency • To respect People we serve and serve with, • To be Accountable to them, to ourselves and to our communities, to passionately deliver excellence in patient care, education, and research, • To be Collaborative and Compassionate in all our efforts, and • To be Transparent and act with integrity in all of our work as a premier academic health system.

In service to our patients and colleagues, I agree with the PACCT and agree to uphold, role model and integrate it in every aspect of my work.

Please check one: • I agree • I do not agree

Policy and Procedures Attestation and Agreement

I understand that I have access to OU Medicine Policies and Procedures via the OU Medicine Intranet or directly through Human Resources in the OUMC Clinic Building located at 711 Stanton L Young Blvd, Suite 103, Oklahoma City, OK 73104. I agree to abide by OU Medicine policies and use them to guide my actions in my role within the facility.

Please check one: • I agree • I do not agree

HIPAA/HITECH Privacy Training

I acknowledge that I have reviewed the HIPAA/HITECH training. I also agree that I will ensure the safety of our patient’s Protected Health Information for every patient, every time.

Please check one: • I agree • I do not agree • I need to discuss further with my supervisor or HR representative

Infant Security Attestation

I have read and understand the Infant Security Policy and I understand that, like all OU Medicine, Inc. and departmental policies, I am expected to practice to that standard at all times. I understand that if I have questions or concerns about the policy or its implementation, I can consult my supervisor or other leaders for clarification and direction.

Please check one: • I agree • I do not agree

Revised 09-2020 3 HIPAA Security Competency Checklist

Instructions: Competency checklist to be used during annual evaluation and at time of departmental orientation.

• Received HIPAA Security training during general orientation or at E&C refresher in last 12 months. • Do you know that passwords should a minimum of 7 characters and comprised of 3 of the following 4 items: lower-case alpha, upper-case alpha, numeric, and special characters? • Do you know how to construct passwords that are not easily guessed? • Do you know never to share your password and to never use another person’s password? • Do you know to never open an attachment in an email message that you are unsure of who the sender is, and to report any potential viruses to the help desk? • Do you know to contact the FISO or ECO if you suspect any form of security incident? This could include viruses, password or media violations, inappropriate use of system, etc. • Do you know to back up all your mission critical files either file servers or local media, and to store in a secure location. I am responsible for assuring my personal files are safe. • Do you know to access information on only a need-to-know basis regardless of access rights? • I know to label all media as confidential if I move any sensitive data to CD, USB drive, tape, etc. • I know that all computer software must be owned and licensed by OUM and installed by the IS department, and to never download software from the Internet without permission from IS. • Do you know to use E Mail and the Internet responsibly and productively to facilitate company business and maintain and enhance the company’s image and reputation? • Do you know to keep a copy of any official Company business records you originate in a mailbox folder or hard copy? • I will not send ePHI or sensitive company information outside of OUM unless it is encrypted to protect it from unauthorized access. I will notify IS if I need those tools. • I understand I am held accountable for protecting all ePHI and that violations are subject to disciplinary action up to termination. • I will use password protected screen savers and assure my computer is physically secure. • I know where to find OUM Security policies. • I understand that all media, CD’s, USB drives, tapes, and other removable media are not to be thrown away. I know to dispose of all removable media through the IS department. • I know to challenge anyone accessing a computer system or entering a secure area who I suspect should not be. • If I must leave a workstation unattended, I understand I am to log off the application and workstation or I must secure the workstation by locking it through Windows or a password-protected screen saver.

Please check one: • I agree • I do not agree

Confidentiality and Security Agreement

I understand that OU Medicine, Inc. and its affiliated facilities and entities (collectively, “OUM” or the “Company”) manages health information as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information.

Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning information, credentialing, intellectual property, or any information that contains Social Security numbers, health insurance claim numbers, passwords, PINs, encryption keys, credit card

Revised 09-2020 4 or other financial account numbers (collectively, with patient identifiable health information, “Confidential Information”).

In the course of my employment/assignment at the Company, I understand that I may come into the possession of this type of Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in accordance with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security Page) and the Internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtain authorization for access to Confidential Information or Company systems.

General Rules • I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during my relationship with the Company. • I understand that I should have no expectation of privacy when using Company information systems. The Company may log, access, review, and otherwise utilize information stored on or passing through its systems, including email, in order to manage systems and enforce security. • I understand that violation of this Agreement may result in disciplinary action, up to and including termination of employment, suspension, and loss of privileges, and/or termination of authorization to work within the Company, in accordance with the Company’s policies.

Protecting Confidential Information • I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a need to know it. I will not take media or documents containing Confidential Information home with me unless specifically authorized to do so as part of my job. • I will not publish or disclose any Confidential Information to others using personal email, or to any Internet sites, or through Internet blogs or sites such as Facebook or Twitter. I will only use such communication methods when explicitly authorized to do so in support of Company business and within the permitted uses of Confidential Information as governed by regulations such as HIPAA. • I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information except as properly authorized. I will only reuse or destroy media in accordance with Company Information Security Standards and Company record retention policy. • In the course of treating patients, I may need to orally communicate health information to or about patients. While I understand that my first priority is treating patients, I will take reasonable safeguards to protect conversations from unauthorized listeners. Such safeguards include, but are not limited to: lowering my voice or using private rooms or areas where available. • I will not make any unauthorized transmissions, inquiries, modifications, or purging of Confidential Information. • I will not transmit Confidential Information outside the Company network unless I am specifically authorized to do so as part of my job responsibilities. If I do transmit Confidential Information outside of the Company using email or other electronic communication methods, I will ensure that the Information is encrypted according to Company Information Security Standards.

Following Appropriate Access • I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals. • I will only access software systems to review patient records or Company information when I have a business need to know, as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmatively representing to the Company at the time of each access that I have the requisite business need to know and appropriate consent, and the Company may rely on that representation in granting such access to me.

Using Mobile Devices, Portable Devices and Removable Media • I will not copy or store Confidential Information on mobile devices, portable devices or removable media such as laptops, personal digital assistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless specifically required to do so by my job. If I do copy or store Confidential Information

Revised 09-2020 5 on removable media, I will encrypt the information while it is on the media according to Company Information Security Standards. • I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes company data (e.g., Company email) may contain Confidential Information and as a result, must be protected as required by Company Information Security Standards.

Doing My Part – Personal Security • I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) track my access and use of Confidential Information and that the identifier is associated with my personal data provided as part of the initial and/or periodic credentialing and/or employment verification processes. • I will: o Use only my officially assigned User-ID and password (and/or token). o Use only approved licensed software. o Use a device with virus protection software. • I will never: o Disclose passwords, PINs, or access codes. o Allow another individual to use my digital identity (e.g., 3-4 User ID) to access, modify, or delete data and/or use a computer system. o Use tools or techniques to break/exploit security measures. o Connect unauthorized systems or devices to the Company network. • I will practice good workstation security measures such as locking up diskettes when not in use, using screen savers with activated passwords, positioning screens away from public view. • I will immediately notify my manager, OUM Information Security Official , OUM Director of Information Technology, or OUM help desk if: o my password has been seen, disclosed, or otherwise compromised; o media with Confidential Information stored on it has been lost or stolen; o I suspect a virus infection on any system; o I am aware of any activity that violates this agreement, privacy and security policies; or o I am aware of any other incident that could possibly have any adverse impact on Confidential Information or Company systems.

Upon Termination • I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my contract, or my relationship ceases with the Company. • Upon termination, I will immediately return any documents or media containing Confidential Information to the Company. • I understand that I have no right to any ownership interest in any Confidential Information accessed or created by me during and in the scope of my relationship with the Company.

By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above.

Please check one: • I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above. • I do not agree • I need to discuss further with my supervisor or HR representative

Revised 09-2020 6 Test

1. AIDET is a communication tool that helps us achieve our service and quality goals. What does AIDET stand for? o Acknowledge, Introduce, Describe, Explanation, Tell o Acknowledge, Instruction, Duration, Explanation, Thank You o Acknowledge, Introduce, Duration, Explanation, Thank You o Acknowledge, Invite, Duration, Explanation, Thank You 2. The tool we used to implement process improvement is o MDAIC o ICMDA o DMAIC o AIDMC 3. For ethical issues concerning patient care, the Medical Ethics Committee can be accessed by o Completing an Ethics consult request form o Calling Risk Management o Contacting an on-call member through the communications operator o Calling hospital administration 4. Upon learning of a patient complaint, the first thing an employee should do is o Follow their chain of command o Complete an occurrence report form o Input the complaint through the RL Solutions link on the Intranet o Take appropriate corrective action as is appropriate for your scope of service 5. An example of an occurrence that should be reported is: o Accidents with or without injury o Medication errors, Treatment delays & IV related complication o Mishaps due to faulty/defective equipment o All of the above 6. The purpose of an investigation of a sentinel event is to do all of the following EXCEPT: o Determine what went wrong with the process o Identify the person responsible and discipline him/her o Find strategies to prevent future occurrences o Find opportunities for improvement 7. It is the policy of OU Medicine to provide written information to all individuals’ ______years of age and older, and emancipated minors, who are receiving medical care about their rights under state law to make decision concerning medical care and formulate an Advanced Directive. o 12 o 18 o 21 o 65 8. If a patient does not have an advance directive, but would like more information about it, the patient should be referred to o his/her Physician o the Clinical Coordinator o the Chaplains/Pastoral Care Services o Social Services 9. Employees have the right to report issues and concerns to regulatory bodies such as The Joint Commission, Department of Human Services or Oklahoma State Department of Health. o True o False Revised 09-2020 7 10. Every hospital death will be recognized as a potential organ/tissue donor. o True o False 11. Under the federal False Claims act, any person that knowingly submits false or fraudulent claim for payment of US Government funds is liable for significant penalties and fines. o True o False 12. The only areas authorized to release information to the media are o Administration o Public Relations/Marketing o Clinical Coordinators, at the OKC Campus o Both B and C 13. Patients will be informed of their privacy rights via the: o Patient Bill of Rights o Notice of Privacy Practices brochures o OU Medicine website o All of the above 14. Patients’ rights include all of the following EXCEPT: o The right to appropriate pain assessment and management o The right to be free from restraint, unless medically necessary o The right to file a complaint o The right to be treated with respect o The right to ignore hospital behavioral expectations o The right to safety and security in the hospital 15. OU Medicine employees wanting information from their medical record should o Print one from Meditech o Fill out a “Release of Information” form in the Medical Records Department o Call the Business Office o None of the above 16. Examples of HIPAA violations include all of the following except: o Taking a picture of a patient with your cell phone to show to students o Forwarding an email from your personal computer with a picture of a patient o Speaking to a family member who has provided a PIN number about a patient’s condition o Explaining the patient’s treatment plan to him while his room is full of visitors 17. Upon receiving a potentially suspicious package, you should immediately alert your supervisor. o True o False 18. In the event of an emergency requiring decontamination, the hospital operator will announce overhead o Mass Casualty Disaster o Medical Disaster requiring decontamination o All personnel activate the Disaster Response Plan at this time o Code Orange – all available personnel please report to your assigned areas. 19. During a disaster/activation of the Emergency Preparedness Plan, each treatment area will maintain a record of patients in and out of their area including patient tracking number, arrival time and departure time. o True o False 20. Upon activation of the Emergency Preparedness Plan, staff shall stay on/report to their department. o True o False Revised 09-2020 8 21. The term used to designate a fire alarm is o Condition Red o Code Red o Code Black o Condition Black 22. If a fire is in your immediate area, your actions should follow the R.A.C. E. acronym. (Rescue anyone in immediate danger, activate the alarm, contain/confine the fire, extinguish the fire if it is safe to do so or evacuate). o True o False 23. If a fire is not in your area, you should do all the following EXCEPT: o Open all doors o Assure patients and families that the situation is under control o Leave someone by the phone o Maintain normal operations 24. Floor Evacuation (vertical evacuation of patient to a lower floor) shall only occur on the order from the Administrator on-call, the House Supervisor, or the Fire Department. o True o False 25. If the emergency generators do not restore power within 10 seconds of loss of normal power, an employee should report the outage to Facilities and Maintenance Dispatch. o True o False 26. When a tornado warning in our area is issued by the National Weather Service, the overhead announcement made will state: o A tornado warning is issued o A Severe Weather Alert is now in effect o Code Black has been issued, Initiate sever weather preparation at this time o Condition Black 27. During a Code Black, it is important to ensure all patients/families/visitors have shoes on or protective foot covering readily available. o True o False 28. Code Blue is the term designated for a patient, staff member or visitor who o Has suffered a cardiac or respiratory arrest and requires cardiopulmonary resuscitation o Has fallen in a stairwell o Has a do not resuscitate order in his medical record o Is on suicide precautions 29. Upon discovering a patient, staff member, or visitor who is not breathing an employee should begin resuscitation if trained in CPR, initiate AED (if available) and call a Code Blue. o True o False 30. Upon discovering an ill or injured visitor or staff member, an employee should report a "person down." o True o False 31. Upon discovering an infant or child missing, an employee should: o Call Police Services and report a Code Pink o Call Police Services and report a Code Adam o Call the hospital operator and report a Code Pink o Call the hospital operator and report a Code Adam Revised 09-2020 9 32. During a Code Pink, if when questioning a person carrying a large purse, bag, jacket etc., he/she refuses a search or exhibits suspicious behavior, you should: o Detain that person o Call the hospital operator with a detailed description o Call Police Services (Downtown)/Security (Edmond) with a detailed description o Walk away 33. In neonatal and perinatal units, staff members wear unique scrubs and have pink ID badges as a heightened security measure. o True o False 34. All staff and contract staff are responsible for ensuring other do not “draft” entrance into a secure area when opening doors with badge access. o True o False 35. Patients at risk for falls or injury from falls will have a sign designating the risk on their door and on the front of their chart. o True o False 36. Employees are responsible for utilizing the appropriate PPE (Personal Protective Equipment) when handling hazardous materials and for reporting potential overexposures and mislabeled hazardous materials. o True o False 37. Chemicals transferred from the original container to another container for storage do not need a label. o True o False 38. Safety Data Sheets (SDS) may be obtained on the intranet or by calling a toll-free number. o True o False 39. When should a piece of equipment should be tagged and locked in the off position? o It is inoperable o It is taken out of service o Its startup could injure someone. o All of the above 40. The person in charge of the unit or Respiratory Supervisor is responsible to shut off/direct another individual to shut off the oxygen supply to that unit in the event of a disaster or fire. o True o False 41. It is acceptable to cleanse your hands with alcohol-based hand sanitizer when your hands are visibly soiled. o True o False 42. Standard Precautions, including wearing appropriate PPE, should be used o When you are concerned that the patient has a contagious disease o When you are certain a patient has a blood borne pathogen disease o In all patient care o When contamination is likely 43. Blood-borne pathogens such as HIV and Hepatitis B can only be transmitted through blood. o True o False Revised 09-2020 10 44. Signs of abuse and/or neglect include all of the following except: o Physical marks (bites, bruises, broken bones, lacerations) o A person telling you he/she has been abused o Crying excessively o Extreme withdrawal or agitation o An unkempt appearance (improper clothing for the weather, extremely poor hygiene) 45. Reporting abuse or neglect is the responsibility of all staff, volunteers, students, etc. o True o False 46. Utilizing population specific care guidelines to carry out their work is the responsibility of all hospital employees. o True o False 47. You can access resources for culturally appropriate care by clicking on the link on the intranet page under the “Medical Reference” tab. o True o False 48. Where can you locate OUM Policies and Procedures? o Meditech o Atlas o Intranet – Policies & Procedures o Internet – Under Employee Resources 49. Which of the following are signs or symptoms of stroke? o Sudden severe headache o Dizziness o Slurred speech o Sudden numbness on one side o All of the above 50. The Code to call if an inpatient is suspected of having had a stroke is: o Code Purple o Code Green o Code Blue o Code Gray 51. According to The Joint Commission, which of the following statements regarding inappropriate abbreviations is not true: o Never use u for units. Spell it out because it can be mistaken for a 4. o Never use qd, qod for daily and every other day. Write out daily or every other day. o Never use a trailing zero. o Always use standard abbreviations for drug names. 52. Vendors may visit the unit to drop off food or pens without going through the HCIR Vendor check in process if they are only going to be in the area a short time and will not have patient contact. o True o False 53. Vendors must have a new badge printed with their name and date each day they are in the facility. o True o False 54. If you are fluent in a foreign language, but have not done an official competency verification, you may translate o Whatever you feel comfortable translating. o Only basic information such as location of bathrooms and treatment areas Revised 09-2020 11 55. Asking a patient’s family member to translate is inappropriate because o We cannot be assured the translation will be accurate o We may need to present information that the patient might not wish the family member to know (creating a HIPAA violation) o Both a and b are correct 56. Which patient population must sign a waiver he/she refuses interpretive services? o Patients who are deaf/hearing impaired o Patients who have limited English proficiency skills o Patients who are blind/have low vision o All of the above 57. Every time an interpreter is used for conveying important information to the patient AND any time inquiries are made about interpretive services, documentation should be placed in the patient’s medical record. o True o False 58. An interpreter with competencies on file must be used in all of the following situations except: o Determining a patient’s history or description of ailment or injury o Obtaining informed consent or permission for treatment o Provision of patient’s rights o Explanation of living wills or powers of attorney (or their availability) o Diagnosis or prognosis of ailments or injuries o Explanation of procedures, test, treatment, treatment options or surgery o Explaining the administration and side effects of medications, including side effects and food or drug interactions o Explaining to the patient how to use the call light o Discharge instructions or planning o Explaining and discussing advance directives 59. Look-alike/Sound alike drugs are those with names that could easily be mistaken for the other and should therefore be stored away from one another. o True o False 60. The High Alert Drugs are identified as such because o They have a high risk for abuse o They are associated with a high percentage of errors o They have been involved with sentinel events o All of the above 61. Staff involved in direct patient care are not allowed to wear nail extenders, artificial nails or have nails longer than ¼ inch beyond the fingertip. o True o False 62. A HIPAA violation can occur if you share information which can be linked back to a patient, even if you do not specifically reveal the patient’s name. o True o False 63. It is permissible to access the medical record of a coworker’s husband who is a patient, to check on his condition if you are curious. o True o False 64. Photographs may be taken using personal devices. o True Revised 09-2020 12 o False 65. Consent to photograph/videotape patients/visitors must be obtained even if the picture does not depict the patient’s face or other identifiable image. o True o False 66. Anytime you leave your workstation you should log off the computer o True o False 67. If you suspect a staff member of mistreating a patient, it is important to immediately report your concern to your chain of command or the clinical coordinator/administrator on call if it is a night/weekend shift. o True o False 68. In the acronym CLEAN helps us remember what to do in the case of a hazardous material spill. The “L” in CLEAN stands for: o Loosely cover the spill o Leave the area unless properly trained to clean up the spill o Locate the Safety Data Sheet 69. It is a requirement in our hospital that medications: o are locked/secured from unauthorized individuals o are under constant supervision o are available 70. In order to maintain the security of medications, It is important that I: o Never allow unauthorized individuals to enter into areas where medications are stored. o Never leave areas where medications are stored unlocked o Never share medication room combination locks with other staff o All of the above. 71. I know where the fire extinguisher, evacuation routes, and oxygen shut off are in my work area. o True o False 72. The purpose of Introducing yourself as part of AIDET is to: o Make the patient feel safe o Reduce the patient’s anxiety o Decrease quality o Increase patient loyalty 73. Regarding Social Media, which of the following statements are true? o Unless specifically authorized, employees may not speak on behalf of OUM. o Employees may not publicly discuss patients, employees, or other stakeholders. o OUM has the right to use content management tools to monitor comments or discussions about the Company, its employees, its patients and the industry posted on the Internet. o Employees should have no expectation of privacy while posting information to social networking sites. o All of the above. 74. Any employee, visitor, practitioner, patient and/or family member, who suspects that a practitioner is impaired, is unable to work cooperatively with others or has exhibited disruptive behavior should o Immediately contact the Departmental Director o Call the Ethics Hotline o Submit a written report to the Chief Medical Officer o Call Administration

Revised 09-2020 13 75. If an employee has a condition or situation which might have an impact on their ability to function in their position, they should o Ignore it and continue working o Notify Human Resources o Notify their supervisor o Notify the Ethics and Compliance Officer 76. Near miss event that should be reported through RL Solutions include: o Verbal or physical violence, threats of physical violence or damage to property o Weapons found on a person (knives with blades over 4”, guns, etc.) o Intentional destruction of property o Any issues that require police intervention o All of the above

Acknowledgement

By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated therein.

Printed Name

Signature Date

Revised 09-2020 14