New Hire Paperwork Check List:



NON-TEAMMATE PAPERWORK CHECKLIST

|Non-Teammate Name: |      |Facility/Bus. Office #: |      |

|Supervisor Name: |      |Facility/Bus. Office Name: |      |

All documents listed below are required for all Non-Teammate (contractors, temps, students, etc.). With the exception of the Non-Teammate Information Form, copies do not need to be sent to People Services.  The Non-Teammate’s supervisor should retain these documents.

Volunteers do not use this form – visit Village Web, PEP department for instructions on how to

register all volunteers.

Non-Teammates-The following needs to be completed for ALL Non-Teammates:

Non-Teammate Information Form (PS 401)

Non-Teammate Compliance Training Acknowledgement (PS 402)

Compliance Training –complete within 21 calendar days of start date. Due date: ____________

Confidential Information Agreement (PS 403)

Computer Use / Electronic Media Access Agreement (PS 404)

System Access Forms (found on Village Web)– If Applicable *

CARA - Used by all hiring managers

MAC – Used by only business office hiring managers

* Not needed for access to EDU System for compliance training.

The following needs to be completed for Non-Teammates working for over 21 Days:

Background & Drug Screen Verification Order Form (PS-405)

Non-Teammate Questionnaire (PS 406)

Background Disclosure / Authorization Form (PS 407)

Acknowledgement Form –Drug Test Form (PS 408)

The following needs to be completed for Non-Teammates upon Termination:

Add termination date to Non-Teammate Information Form (PS-401) and fax to People Services at 303-626-6339.

Terminate the Non-Teammate in CARA; also in MAC if in the Business Offices.

Completed by: _______________________________________________ Date: __________________

NON-TEAMMATE STEPS

1. Non-Teammate and Supervisor completes all applicable forms in Non-Teammate Packet.

2. Fax Non-Teammate Information Form (PS-401) to People Services at 303-626-6339. Upon receipt, PS will process and generate an ID number. ID number will be sent via email to Non-Teammate’s supervisor.

3. Fax Background & Drug Screen Verification Order Form (PS-405) and Background Disclosure / Authorization Form (PS-406) and Non-Teammate Questionnaire (PS406) to background screen provider (fax number located on Drug & Background Verification Order Form (PS-405)). Supervisor will be notified via email by eScreen.

4. Send Non-Teammate for Drug screen. Supervisor will be notified via email by eScreen.

5. Upon receipt of Non-Teammate ID number, Non-Teammate MUST complete Compliance Training within 21 calendar days of start (see Workforce Compliance Training Policy).

6. Upon Non-Teammate termination, add termination date to Non-Teammate Information Form (PS-401) and fax to People Services at 303-626-6339.

Non-Teammate Information Form

See page footer for distribution instructions

Facility Type: Clinic New Acquired/Built Business Office

|First Name |      |Middle Initial |      |Last Name |      |

|(required): | | | |(required): | |

|Start Date |      |Date of Birth |      |Last 4 Digits of SSN |      |

|(required): |*First Date of Service |(required): | |(required): | |

| |Performed* | | | | |

|JOB TYPE (required – select one): |

|Clinical/Operations |Non-Clinical |

| |RN/LPN/LVN | |People Services |

| |Patient Care/Inventory/Resuse Tech | |IT |

| |BioMed Tech | |ROPS, A/R, Billing |

| |Facility Administrator | |Medical Records |

| |Regional Operations Directory | |Compliance |

| |Division Vice-President | |Legal |

| |Clinical/Operations Other       | |Purchasing |

| | | |Vice President/Executive |

| | | |Non-Clinical Other      |

|Type of Non-Teammate (Required): |

| |Student | |Temporary Agency Worker (Agency Name      ) |

| |Contract Worker | |IT Consultant |

| |Aurora Medical Group Employee | |Research Coordinator |

| |RMS Lifeline Physician | |RMS Lifeline Physician Employee |

| |Village Health Physician | |Village Health Physician Employee |

|Non Teammate Title: |      |Description of Services Being |      |

| | |Performed: | |

|Location Code/ |      |GL Dept # |      |Department Name: |      |

|Center # (required): | |(required): | | | |

|Supervisor Name (required): |      |Supervisor ID#: |      |Supervisor Phone: |      |

|Non Teammate Home Address: |      |Non-Teammate Home Phone #: |      |

|City/State and Zip Code: |      |Non-Teammate Business Phone #: |      |

|Emergency Contact Name: |      |Emergency Contact Phone #: |      |

|Supervisor Signature: | |Date: |

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CONFIDENTIAL INFORMATION AGREEMENT

I understand the importance of preserving the confidential nature of the information of DaVita, Inc. and their related companies (together DaVita). This includes, but is not limited to, DaVita’s data and records relative to business interests, insider information, computer systems, software, and programs, projections, business plans, inventions, trade secrets, know-how, as well as information wherein DaVita has an obligation of confidentiality to a third party and information concerning any patient, teammate, physician, medical director, agency teammate, independent contractor, student, fellow, volunteer or workforce member. I understand the necessity that such information not be compromised or disclosed for any reason other than necessary business or medical communications and treatment needs.

I further understand that patient information is confidential and not to be discussed with or disseminated to anyone, either inside or outside the company, except on an as-needed basis solely for the purpose of the treatment of the individual, payment related thereto, or for DaVita’s healthcare operations in full compliance with all applicable federal and state regulations. Unauthorized dissemination may be a violation of federal and state laws.

I am also aware and fully understand that any violation of this Confidential Information Agreement is grounds for corrective action, up to and including immediate termination of employment or termination of any work or project related contract or agreement between DaVita and any of its subsidiaries and/or related organizations by which I am bound. I fully understand that DaVita may use all remedies available to seek damages and compensation for any disclosure or compromise of confidential information including any available criminal penalties.

|Name: PLEASE PRINT |      |

|Signature: |x |

|Non-Teammate ID#: |      |

|Company Name: |      |

|Date: |      |

Affiliation – check which one applies

|DPD DaVita | |Student | |Temporary Agency Worker: | |

|Te Teammate | | | | | |

|Consultant | |Contractor Worker | |Attending Physician | |

| Medical Director | |Nephrology Fellow | | | |

FORM

COMPUTER USE / ELECTRONIC MEDIA ACCESS AGREEMENT

As a user of DaVita, Inc.’s (the “Company”) information technology systems and equipment, there are certain guidelines that I must follow. By signing this document (this “Policy”), I agree to the following guidelines:

User Id and Password

1. I am responsible for all activities performed under my User ID and password and will abide by the policies and procedures related to the use of my Login ID and password.

2. I understand that my password and any User ID I select should be unique and non-trivial (not my name, birthday, car type, etc.) and that I must maintain the confidentiality of my password and User ID and not share it with unauthorized persons.

3. I will notify the Information Technology Group if I suspect that the confidentiality of my password has been violated or when I no longer require access to a particular system.

Privacy and Disclosure

1. I will not disclose or distribute any confidential information relating to teammates, products or the business of the company without proper authorization.

2. I will not disclose or distribute any patient information without proper authorization. I will not disclose or distribute electronic versions of a patient or teammate's personally identifiable health information unless I have complied with DaVita’s policy regarding Transmitting Protected Health Information via Fax, Telephone and E-Mail as outlined in DaVita’s Policy and Procedures manuals. All electronic disclosures or distributions of a patient and teammate's personally identifiable health information shall be limited to the minimum necessary information.

I realize that the information I publish electro

3. I realize that the information I publish electronically (sometimes called a "posting") reflects on the Company in general. I understand that despite all disclaimers that I make (e.g., that my views are my own and may not reflect those of my employer) readers elsewhere will make the association between my posting and the Company. True anonymity is very difficult to obtain when using the Company’s computers, e-mail, voicemail, and facsimile, Internet and Intranet access and other software (“Resources”).

4. Accordingly, I will make all reasonable efforts to be professional in all usage of Company Resources. Postings should never reference unannounced products or unpublished details about Company technology. I understand that my postings also should not compare or contrast different products or customers, advocate one customer or product in favor of another, or refer to our competitors either directly or indirectly.

5. I understand that information transmitted using the Company Resources or stored on Company owned computers will not necessarily remain private. These systems are owned and/or controlled by the Company and are accessible at all times by the Company for maintenance, upgrades, or any other business or legal purposes.

Systems and Equipment Use

1. I understand that the Company provides the Resources for business purposes. The Resources and all messages, documents and data, produced, carried or stored by such Resources are property of the Company, subject to reasonable inspection by the Company. I also understand and agree that the following uses of these Resources are inappropriate:

a. For illegal purposes or in support of illegal activities. The Company reserves the right to cooperate with legal authorities and/or injured third parties in the investigation of any suspected criminal or civil wrong.

b. Posting or forwarding e-mailing scams such as 'make-money-fast' schemes or pyramid/chain letters.

c. Attempting to access the accounts of others or attempting to penetrate the Company’s Information Security ("hacking"), whether or not any intrusion results in corruption or loss of data.

d. To mislead the recipient of any message as to the actual identity of the sender.

e. To express your personal opinion as the opinion of the Company.

f. To e-mail or store any material that a reasonable person could construe as defamatory, derogatory, discriminatory, harassing, disparaging, offensive or obscene.

g. To send confidential information without proper protections and authorizations.

h. Excessive personal use.

i. Using Resources for personal financial gain, or to solicit others for activities, or in connection with political campaigns or lobbying unrelated to the DaVita's business.

j. Knowingly distributing viruses or failing to take reasonable precautions, as instructed by the system manager, to prevent the spread of viruses.

k. Misrepresenting my identity in any way while using the Resources.

2. Unless and until deployed officially within a business unit, I understand that tools such as real-time audio, desktop videoconferencing, and web casting should be used sparingly, if at all.

3. E-mail and voice-mail messages and computer-stored items are all property of the Company and may have legal and operational effect identical to that of traditional, hardcopy documents. Accordingly, I will compose record and store all e-mail messages as though they may later be viewed by others.

4. It is my responsibility to keep abreast of and comply with newly implemented computer policies provided to me and/or brought to my attention.

5. I understand I am responsible for reporting any activity that I believe in good faith may be a violation of this policy.

Ownership and Monitoring

1. I agree that all my work product utilizing Company Resources, (which includes any and all intellectual property, ideas, themes, concepts, computer programs, and other documentation), belong to and are the sole property of the Company.

2. I understand the Company owns all systems, data and documents and has the right to monitor the use of the systems accessed by individual users. The Company has the right, for any reason whatsoever, to gain access to and print all documents transmitted or stored on Company systems and software.

3. When making use of these Resources I know that I have a very limited expectation of privacy. I understand the Company has the right to periodically monitor the Internet sites accessed by

individuals and those individuals who inappropriately access Internet sites may be subject to corrective action, which could include termination of my employment or contract.

4. I agree to return to the Company all documents, data and e-mail in my account upon termination of employment, any employment related contract, consulting agreement or agreement between the Company and any of its subsidiaries and/or related organizations by which I am bound.

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Original to Supervisor’s File

• Copies to Non-Teammate

PS-404

Rev.11/06

5. I will not violate copyright or trademark laws nor knowingly introduce unlicensed software into any system. This includes all software residing on individual PCs or file servers. Each system must have its own original licensed copy for all vendor software programs (e.g. Windows, Word, Excel etc.), or be covered by a comprehensive site license. I understand that copyright infringement includes copying and/or distributing materials found on the Internet without the consent of the copyright owner. These materials include images, text, video and audio materials, software, information and inventions.

I understand that my failure to follow the guidelines in this Policy may result in corrective action, including termination of my employment or contract, as well as any other action that the Company deems necessary or advisable to take, including criminal prosecution or civil action.

User's Printed Name:      ____________________________

Facility Location:      ____________________________

User’s Signature: X_________________________________

Date:      _____________________________

Non-Teammate ID:      _____________________________

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Original to Supervisor’s File

• Copies to Non-Teammate

PS-404

Rev.11/06

|Fax: 1-913-234-4508 |DRUG SCREEN & BACKGROUND VERIFICATION |Resource Hire Job ID # |

|Fax This Form, Application (not needed for|ORDER FORM |     ________ |

|Level 5 or 6) and Disclosure/Release | |YALE# 886000 |

|eScreen Client Services: | | |

|1-800-881-0722 Option 5 | |Total # pgs. |

| | |Including this form       |

NOTE: Level 5 will NOT undergo a Drug Screen unless you Checkmark below

|Facility #: |      |( Applicant is a remote hire; applicant’s zip code =       |

|Facility Name: |      |Division Name: |      |

|City/State |      |Date: |      |

|Ordering Official: |      |Time of Order: |      |

|Email: |      | | |

|Telephone #: |      |Fax# |      |

|Applicant Name: |      |Soc. Sec. No.: |      |

|Applicant Tel. #: |      |Date of Birth |      |

|Applicant Email (Required)| | | |

| |      | | |

|Report Type |Description |Drug Screen |

|(Check One) | | |

|Level 1 |Non-Caregivers, Finance, ROPS, Non Clinical Supervisor and Above: |( |

|( |Employment History – Last 2/SSN Verification / Education-Highest Degree | |

| |Criminal - 7 Yrs (max 5) /National Sexual Offender/ OIG (HHS)/ GSA | |

| |Exclusions Lists / Terrorist List (OFAC-SDN) | |

|Level 2 |All Licensed Personnel, Caregivers (Including PCTs, Bio-Med), Clinical Supervisor and Above: | ( |

|( |Level 1 Plus: Professional License Verification* / Certification* & Designation/ | |

| |Professional Disciplinary Action Search | |

| |*Type of license/certification ________________________State_____ | |

|Level 3 |DaVita Temps & Contractors Clinical (Greater than 21 Day Assignment) | |

|(Clinical) |(Same as Level 2) |( |

|( |Use DaVita Non-Teammate Questionnaire | |

|Level 4 |DaVita Temps & Contractors NON-Clinical (Greater than 21 Day Assignment) (Same as Level 1) | |

|(Non Clinical) |DaVita Temps and Contractors NON Clinical working less than 21 days must have a license verification and | |

|( |Compliance check verified completed by the location. Check License Option below in such cases |( |

| |Use DaVita Non-Teammate Questionnaire | |

|Level 5 |Students/Externs (Greater than 21 Day Assignment) (Same as Level 6) |(Checkmark if needed) |

|( |If providing “hand on care” a drug test is required. | |

| |Students and Externs working less than 21 days must have license verification & Compliance check verified| |

| |completed by the location. Check Options below. | |

OPTIONAL SERVICES (CHECK as Applicable)

NPDB Credit MVR D/L#     _____________ State:      _____________

License Verification: Type      ________________ State:      ______________

Compliance Check (OIG/GSA Exclusions)

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Originals to Supervisor’s File

• Copies to Non-Teammate

PS-405

Rev11/06

NON-TEAMMATE BACKGROUND QUESTIONNAIRE

Please Print Legibly Date:      _________

Personal

|Last Name |First |Middle |Social Security Number |

|      |      |      |      |

|Present Address |City |State |Zip |Phone |

|      |      |   |      |      |

|Date of Birth |Driver’s License and State |

|      |      |

Employment History – beginning with most recent employer

|Employer Name: |Street or Mailing Address | | | |

| |      |City |State |Zip |

|      | | | | |

| | |      |   |      |

|Supervisor (Name and Title) |Phone |

|      |      |

|Job Title/Description of Duties |Employment Dates (Mo/Yr) |

|      |      |

| If presently employed, may we contact this employer for verification? Yes No |

|Next Employer |Street or Mailing Address | | | |

| |      |City |State |Zip |

|      | | | | |

| | |      |   |      |

|Supervisor (Name and Title) |Phone |

|      |      |

|Job Title/Description of Duties |Employment Dates (Mo/Yr) |

|      |      |

|Next Employer | | | | |

|      |Street |City |State |Zip |

| |      |      |   |      |

|Supervisor (Name and Title) |Phone |

|      |      |

|Job Title/Description of Duties |Employment Dates (Mo/Yr) |

|      |      |

Education – List Highest Degree

|School Name |City/State |Dates Attended |Degree Earned |

|      |      |      |      |

Professional License or Certification (Only if applicable to the position)

|License Type/ Number |State |

|      |   |

Have you ever been convicted of a crime except minor traffic offenses, marijuana-related misdemeanor convictions occurring more than 2 years ago, or criminal convictions for which the record has been expunged, sealed or eradicated by the court, or misdemeanor convictions for which any probation has been completed and the case dismissed by the court?

Yes No If Yes, please provide details, date, court and disposition for each case: ________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________ Date:      _____________

Signature

DISCLOSURE / AUTHORIZATION

RELEASE OF INFORMATION

|NAME (PLEASE PRINT): |      |DATE: |      |

In connection with my application for employment, or in order for DaVita to consider me for a volunteer position, a student internship, temporary or staffing agency placement, or other non-employment relationship (hereafter “non-employee”) with DAVITA INC. (hereafter DAVITA), I authorize the procurement of a consumer report and understand that it may contain information about my background, character, general reputation, mode of living, and credit worthiness. I understand that, upon written request within a reasonable period of time, I am entitled to additional information concerning the nature and scope of this investigation. I understand that pursuant to the Fair Credit Reporting Act (FCRA), I have the right to know if adverse action is being considered against me as a result of information contained in this report, that I have the right to a copy of this report prior to any adverse action taken against me and to dispute the accuracy of any information in this report by contacting the consumer reporting agency, YALE ASSOCIATES, INC. (hereafter YALE), whose address and telephone number are listed at the bottom of this form. I understand that I may have additional rights under State law which I may determine by contacting my State or local consumer protection agency. I hereby release DAVITA, YALE, their officers, agents, employees, and servants from any liability arising from the preparation of this report or investigations relating thereto.

This authorization for release of information includes, but is not limited to, matters of opinion relating to my character, ability, reputation and past performance. I authorize all persons, schools, companies, corporations, credit bureaus and law enforcement agencies to release such information without restriction or qualification to YALE, and any of its officers, agents, employees and servants. I voluntarily waive all recourse and release the above sources and firms, including DAVITA and YALE, from liability for complying with this authorization.

This authorization will be valid for any future consumer report(s) as may be necessary during my employment or my non-employment relationship with DAVITA. Should I be hired into or transferred into an acute position at a hospital or other third party facility, I authorize that a copy of any such required background report or investigative consumer report be shared with that third party agency.

I understand that any offer of employment (or acceptance as a non-employee) by DAVITA will be contingent upon the results of a number of factors including this background check.

|Social Security #: |      |Date of Birth: |      |

|Signature & Date: |      |Other Names Used: |      |

| | | |      |

California, Minnesota and Oklahoma residents may obtain a copy of this report by checking this box.

*Date of birth is required solely for the purpose of verifying background information and to insure accuracy in the search of public records. It will be used for no other purpose.

RESIDENCE INFORMATION

Please provide all home addresses for the most recent seven (7) years, starting with your present address.

| |Street Address |City |State |Zip |Dates |Month/Day/Year |

|1) |      |       |       |       |From |       |

| | | | | |To |      |

|2) |      |       |      |       |From |       |

| | | | | |To |      |

|3) |      |       |      |       |From |       |

| | | | | |To |      |

|Yale Associates, Inc. |

|1150 Portion Road, Holtsville New York 11742 |

|Tel: 631.732.4400 Fax: 631.732.2194 |

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Originals to Supervisor’s File

• Copies to Non-Teammate PS-407 Rev. 11/06

ACKNOWLEDGEMENT FORM

DRUG TEST

DaVita is a drug-free workplace. It is a violation of company policy to possess, use, sell, purchase, or transfer drugs on company property. This prohibition not only applies to illegal narcotics but also to the possession of prescription narcotics without a prescription, as well as, prescription narcotics that are taken in violation of the prescription. It is also a violation of company policy to be under the influence of drugs or alcohol while on company property or during work hours. Non-teammates who violate this policy are subject to discipline, up to and including termination. Non-teammates are also subject to reasonable suspicion drug and alcohol testing.

As a condition of assignment with DaVita, you must successfully complete a drug test before becoming a non-teammate. All offers of assignment are conditioned upon a successful completion of a drug test. If you do not successfully complete a drug test, DaVita’s offer of assignment will be revoked.

Drug testing is conducted for the presence of the following illegal drugs: cocaine; marijuana / cannabinoids (THC); amphetamines/methamphetamines; phencyclidine (PCP); and opiates.

A non-teammate does not successfully complete a drug test if he/she tests positive for narcotics, refuses to take the drug test, tampers with the sample, or in anyway interferes with the test.

DaVita will maintain the confidentiality of all test results. In addition, you will have the right to confidentially report to a medical review officer the use of any prescription or nonprescription medication and to explain the results of a positive test result.

If you are advised that you were denied the assignment because of a positive test result, you may contest or explain the result within five (5) working days after receiving written notification of the test result. You also have the right to a copy of the results of your drug test.

     _______________________      _______________

Name of Non-Teammate (Please Print) Date

x________________________________________

Signature of Non-Teammate

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-----------------------

Distribution:

• Fax Non-Teammate Information Form Only to: People Services, Fax #303-626-6339

• Originals to Supervisor’s File at Facility

• Copies to Non-Teammate

PS-400

Rev. 04/07

Distribution:

• Fax Non-Teammate Information Form Only to: People Services, Fax #303-626-6339

• Originals to Supervisor’s File at Facility

• Copies to Non-Teammate

PS-401

Rev. 05/07

Distribution:

• Fax Non-Teammate Information Form Æ{| [pic]¢¥[pic]Ч[pic]&ª[pic](ª[pic]^ª[pic]`ª[pic]tª[pic]vª[pic]xª[pic]‚ª[pic]„ª[pic]¤ª[pic]¦ª[pic]ºª[pic]¼ª[pic]¾ª[pic]Ȫ[pic]ʪ[pic]̪[pic]Ϊ[pic]òª[pic]ôª[pic]to: People Services 303-626-6339

• Originals to Supervisor’s File

• Copies to Non-teammate

PS-403

Rev. 02/07

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Originals to: Supervisor’s File

• Copies to: Non-Teammate

PS-404

Rev. 11/06

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Originals to Supervisor’s File

• Copies to Non-Teammate

PS-406

Rev. 02/07

[pic]

Distribution:

• Fax Non-Teammate Information Form to: People Services 303-626-6339

• Originals to Supervisor’s File

• Copies to Non-Teammate

PS-408

Rev.11/06

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