Professional Letter



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VERIFICATION CHECKLIST

Clinical

Registry / Contract / Temporary Staff

The following Orientation and Education requirements and documents must be completed at the agency in order to work at UCLA Faculty Practice Group as a registry, contract or temporary staff member.

1. Copy of completed Agency Application

2. Verification of (3) signed Abuse Reporting Statements (child, domestic, elder)

3. Verification of signed Confidentiality Statement

4. Verification of completed HIPAA Training Module and Post Test

5. Evidence of Medical Criteria Clearance/TB Testing/ Drug Screening Completion

6. Evidence of Background Check completion

7. Verification of valid License/Certification/CPR Card (if applicable)

8. Evidence of completed C-ICARE Training Module and Post Test

9. Evidence of completed Code of Conduct Module and Post Test

10. Evidence of completed Age Specific Education Module and Post Test (if applicable)

11. Review of Sedation Guidelines (if applicable)

12. Review of Restraints Guidelines (if applicable)

13. Review of Nondiscrimination Policies

An original license, certification and/or CPR card must be presented to UCLA Faculty Practice Group personnel before starting any assignment. These documents must be current at all times.

I, ____________________________ have completed, signed and understand the above required documents and requirements and am ready to begin my assignment at UCLA Health System. I am aware that my personnel file can be audited at any time by UCLA Faculty Practice Group Human Resources for compliance purposes.

____________________________________ __________________

Temporary Staff Employee Signature Date

____________________________________ __________________

Temporary Agency Representative Date

____________________________________ __________________

Agency Name Agency Phone Number

*** Confirmation of valid license/CPR card (if applicable) ***

________________________________________ ___________________

UCLA Department Manager/Designee (Signature) Date

________________________________________ ___________________

UCLA Department Manager/designee (Print) Date

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