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Physician Employed Personnel (PEP) Initial Application PHYSICIAN EMPLOYED PERSONNEL INITIAL APPLICATION NAME LAST FIRST M.I. □ THE OUTER BANKS HOSPITAL □ VIDANT DUPLIN HOSPITAL □ VIDANT BEAUFORT HOSPITAL □ VIDANT EDGECOMBE HOSPITAL □ VIDANT BERTIE HOSPITAL □ VIDANT MEDICAL CENTER □ VIDANT CHOWAN HOSPITAL □ VIDANT ROANOKE CHOWAN Page 1 of 5 Physician Employed Personnel (PEP) Initial Application Physician Employed Applicant Information □ Initial Appointment Please check appropriate category: □ RN □ LPN □ Dental Assistant □ Surgical Assistant □ Office Assistant □ Researcher □ Medical Physicist □ Lithotripsy □ Radiology Coordinator □ Other: _______________________________ Please specify the Vidant Health Department you will be working in: __________________________________ Please provide estimated percent of time spent at above designated Vidant Health entity:________________ (10%, 50%, 90%, etc.) __________________________________________________________________________________________________ New Applicant’s Full Legal Name: ______________________________________________________ Applicant’s Social Security #: ______/_____/_______ Date of Birth ______________ Home Address: ___________________________________________________________________________ (Street) ___________________________________________________________________________ (City) (State) (Zip) Telephone #: ___________________________ Email: ____________________________________ Employer and Sponsoring Physician Information Employer Practice/Group Name: __________________________________________________________ Sponsoring Physician from Practice/Group: __________________________________________________ Employer Address: ______________________________________________________________________ (Street) _______________________________________________________________________ (City) (State) (Zip) Office Telephone #: ____________________ Fax #: ________________________ Office Manager: _____________________________ Manager’s Direct Telephone #: ______________________ Manager’s email: _________________________________________ Page 2 of 5 Physician Employed Personnel (PEP) Initial Application Licenses and Certifications (Please attach copy) Name: _______________________ # __________________ Date Issued: ______________ Exp: _____________ Name: _______________________ # __________________ Date Issued: ______________ Exp: _____________ 1) Have you ever been convicted of a criminal offense? □ No □ Yes If yes, list offense, conviction date, and whether a misdemeanor or felony. 2) Has your license to practice in any jurisdiction, been suspended, limited, restricted, reduced, revoked, denied or not renewed within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application. 3) Have you been placed on probationary status or been reprimanded or cautioned by a state licensing or regulatory agency within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application 4) Are there any challenges to your licensure or registration currently pending? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application. 5) Have you voluntarily or involuntarily surrendered a license, registration, membership, at any institution within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application. EDUCATION: Please note that documented verification of education and training may be requested. College(s) or Tech(s): Degree(s) Obtained: Years Attended: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ PREVIOUS WORK EXPERIENCE (include training background and/or informal on-the-job training by physicians): __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Page 3 of 5 Physician Employed Personnel (PEP) Initial Application List PEP job description/duties/responsibilities in full detail below: May attach Job description for PEP role ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ List VIDANT supervising physicians – Vidant Health Medical Staff __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PLEASE SUBMIT COPIES OF ITEMS LISTED BELOW • Liability Insurance • Licenses/Certifications (including current BLS/ACLS card if required) • Immunization documentation including Flu shot (seasonal), 2-step PPD (2 reads within past 12 months). Other Immunization documentation that could be included: Varicella, Tdap, MMR 1&2 • Background check attestation letter • Specific Competency Validation Form (if applicable) • Waiver Responsibility Form • Confidentiality Form • Code of Conduct Form • 11 Learn module certificates (print out with name) • Other documentation as requested Page 4 of 5 Physician Employed Personnel (PEP) Initial Application READ CAREFULLY BEFORE SIGNING Physician Employed Applicant (PEP) In completing this application, I attest that I have no known health conditions that would interfere with my work. I agree to abide by all Policies and Procedures that apply as if I was an employee of Vidant Health. I am expected to abide by a high standard of ethical behavior at all times. I agree to obey the laws and rules that apply to Vidant Health’s operation and to my particular duties. I will abide by the organization’s compliance program/Code of Conduct and understand that I have a duty to report potential violations to the compliance officer. I commit to supporting Vidant Health’s mission: To improve the health and well-being of Eastern North Carolina. I certify that the statements herein are made truthfully without evasion and agree that the statements may be investigated and if found materially inconsistent my request may be denied. I consent to verification of the credentials cited in this application and authorize the release of such information from the institutions. A copy of this statement shall be as binding as the original. _________________________________________ ___________________ Applicant Signature Requesting PEP Access Date Sponsoring Physician Statement This is to certify that the employee completing this application is under my supervision, and I assume responsibility for his/her work. I have received and agree to follow the Policies and Procedures regarding Physician Employee Personnel and agree that the above mentioned employee is qualified and competent to perform the scope of practice/privileges he/she is requesting. I assure that if this employee does not have liability insurance that I as her supervising physician will make provisions for such liability insurance coverage while the employee is providing services at Vidant Health and that this information is updated annually. I will notify you promptly of the employee’s termination as my employee or supervisee. _________________________________________ ___________________ Sponsoring Physician Signature Date _________________________________________ Sponsoring Physician Print Name Approval or Denial - This portion is for Official Use Only Approved: □ No □ Yes Denied: □ No □ Yes Vidant Health Designee: __________________________________ Date: _______________ (signature) Vidant Health Designee: _______________________________________________________ (print name) Page 5 of 5 .

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