Orientation Checklist

Employee Information Form

Step 1 of 6
Employee Name*

First NameLast Name
Professional Title *
Social Security Number
Date of Birth*

MonthDayYear
Hire Date (For office use only)

MonthDayYear
Employee E-mail Address
Employee Contact Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Rate of Pay
For office use only
Emergency Contact

First NameLast Name
Relationship to Employee
Emergency Contact Number

Area CodePhone Number
Signature: By Signing this document I certify that all information I have provided above is true and correct.*

For office use only
Termination Date (For office use only)

MonthDayYear
Rehire Date (For office use only)

MonthDayYear
Termination Date (For office use only)

MonthDayYear

Agreements Section

Step 4 of 6
Policy and Procedure Agreement
I have read, understand and agree to abide by the policies and procedures set forth by Abundant Life Home Health Agency, LLC.

I also understand that I may view or copy any or all of Abundant Life Home Health Agency policy and procedure manual for review or retention.

I also agree to adhere to all local, state and federal procedures regulated as precedent for the home health care industry for compliance in providing care to Agency clients as designated.
Infection Control
I have read the Blood Borne Pathogens Policy. I understand and agree to comply with all provisions of the policy.
Employee Acknowledgement of Handbook
I acknowledge receipt of Abundant Life Home Health Agency, LLC Employee Handbook. In consideration of my employment I agree to read and abide by the rules and the policies of this handbook. Since the information, policies, and benefits described in this booklet may be subject to change, I understand and agree that any such change can be made unilaterally by the company in its sole and absolute discretion, and that material changes will be made known to employees through the usual methods of communication within a reasonable period of time.
Job Acceptance Statement
have been given a copy of my job description. I have read and agree to the terms specified in this description for the position I am applying for/currently hold. I further understand that this job description may be reviewed at any time and I will be provided with a revised copy should any revisions be made.

I understand and agree with the above statement. I have had the opportunity to ask questions and have had my questions answered.
Position Applied for: *
AGREEMENT TO ARBITRATE EMPLOYMENT CLAIMS
1. Employee is employed by Company on an at-will basis. Employee is not subject to the terms of any individual written employment contract or collective bargaining agreement between Employee and the Company. This Agreement to
Arbitrate Employment Claims agreement and the Conditions of Employment are the only written agreements between the Employee and the Company and except as expressly set forth herein, is intended to modify the employee-at-will relationship between the Employee and the Company to require arbitration of all employment disputes under the Federal Arbitration Act. Both parties waive the right to a judge or jury trial, except as provided in the Federal Arbitration Act.
2. In consideration of the continued employment relations between Employee and the Company, the Employee and the Company agree that any legal or equitable claims or disputes arising out of, or in connection with the Employee’s employment status, continued employment, terms and conditions of continued employment, employment-related disciplinary action, or the termination of employment, including related claims against other officers, employees or agents of the Company, will be settled by binding arbitration. Claims that are subject to arbitration include, without limitation, those arising under Title VII of the Civil Rights Act of 1964, the Age Discrimination and Employment Act, the Older Workers Benefit Protection Act, the Americans with Disabilities Act, the Employment Retirement Income Security Act, the Fair Labor Standards Act, or any federal law, or any civil rights, human rights, labor or employment law, rule, regulation or decision of any other state in the United States, or any other jurisdiction or country. This Agreement is intended to apply to claims involving Employee, Company and Company’s customers. The parties agree that Company’s customers are third party beneficiaries of this Agreement.
3. Except as modified by this Agreement, the arbitration will be conducted in accordance with the rules of the American Arbitration Association, and shall be conducted in the City of Clearwater, Fl, 33761.

4. The arbitration procedure and results shall be equally binding on the Employee and the Company.

5. In the event that a mutually binding arbitrator cannot be selected by both parties, each party shall select an arbitrator and the two arbitrators shall select a third arbitrator and the matter shall be heard by a panel of the three arbitrators. Decisions will be by majority vote of the arbitrators. The arbitrator(s) shall have exclusive jurisdiction to interpret and enforce this agreement, including determination of arbitrability of any claim.

6. All costs and expenses of arbitration, except attorney’s fees and expenses, shall be borne equally by the Employee and the Company. Each party agrees to pay their own attorney’s fees and expenses and waives any claim against the other party.

7. Except as expressly modified herein, all damages available at law or in equity shall be available to the parties. The arbitrators shall issue a written opinion that summarizes the issue in dispute, describes the awards, and explains the reasons for the outcome.
COVID-19 Vaccine Policy and Procedures
I received and read a copy of Abundant Life Home Health Agency's COVID-19 VACCINE POLICIES AND PROCEDURES, dated February 3, 2023, and understand that it is my responsibility to be familiar with and abide by its terms. I understand that the information in this policy is intended to help Abundant Life Home Health Agency's employees to work together effectively on assigned job responsibilities. This policy is not promissory and does not set terms or conditions of employment or create an employment contract.
Agreement for E-Verify
I acknowledge that I have read and understood the information above. I understand my rights and the rights of the company to provide form I-9 to confirm that I am authorized to work in the US.
In-service Documentation:

Alzheimer’s Disease (AD) and Related Dementias
This document verifies that I have read and understand the literature prepared by the Florida Health Care Association with the assistance of the Alzheimer Resource Center of Tallahassee, Florida to meet statutory requirement of 400.4785 (1) (a) F.S.
HIPAA Training
The in-service includes:
Definition
PHI
Covered entities
HIPAA specific policy to the agency
Length of in-service: 1 hour

Medical Device Reporting & MSDS Training
The in-service includes:
Hazard communication requirements of OSHA
The presence of hazardous chemicals in the work area
How to cope with emergency procedures (recognition, reporting, and evacuation)
How to read and interpret labels and MSDS
Medical device reporting policy and procedures
Length of in-service: 1 hour

AIDS/HIV/Bloodborne Pathogens Training
The in-service includes:
Definition
Ability to identify at risk populations for HIV/AIDS
Recognize new health concerns in HIV patients
Recognize importance of infection control in the workplace
Identify OSHA regulations regarding bloodborne pathogens
Identify regulations regarding sharps safety and handling
Length of in-service: 2 hour
I certify that I have attended the above listed in-service sessions. I have been given an opportunity to ask questions and have received clarification about the subject matter or policy/procedure involved. I understand how the materials presented apply to my work and agree to implement them to the best of my ability.
By signing this document, I agree to all terms and conditions above. This certifies that I have read and understood the policies for:

Policy and Procedure Agreement

Infection Control

Employee Acknowledgement of Handbook

Job Acceptance Statement

Agreement to Arbitrate Employment Claims

COVID-19 Vaccine Policy and Procedures

E-Verify Agreement

In-service Documentation: Alzheimer’s Disease (AD) and Related Dementias
Signature: *

Limpiar
Employee Name *

First NameLast Name
Date Signed *

MonthDayYear
Date

	Yes	No
Have you ever received a BCG? (TB vaccination) This question is for people that have been pre-vaccinated, usually from other countries.
Have you been exposed to an isolated case of TB this year?

	Yes	No
Chronic cough
Chronic cough with sputum/color ___________________________
Persistent night sweats
Involuntary weight loss
Chronic fatigue
Any serious illness

	Competent	Never Done	Needs Review	N/A
Demonstrates ability to perform a nursing assessment of a patient (RN only
Completes realistic and measurable goals based on identified needs or problems (RN only)
Uses appropriate interventions to carry out the plan of care (RN only)
Observes and evaluates the care being given and makes the appropriate changes when necessary (RN only)
Admission (RN only)
Re-certification (RN only)
Discharge (RN only

	Competent	Never Done	Needs Review
Demonstrates effective communication skills
Provides the patient and caregiver with appropriate patient education
Demonstrates appropriate understanding of medications frequently utilized
Demonstrates safe/effective administration of medications: oral and sublingual
Demonstrates safe/effective administration of medications: Intramuscular injections
Demonstrates safe/effective administration of medications: subcutaneous injections
Intradermal
Suppositories
Topical agents
Inhaled medications
Venipuncture/ blood draws
Discontinue IV

	Competent	Never Done	Needs Review
Appropriate wound care: pressure ulcer prevention
Appropriate wound care: pressure ulcer treatment
Appropriate wound care: skin tears
Appropriate wound care: care of grafts
Appropriate wound care: care of donor site
Appropriate wound care: documentation
Appropriate wound care: suture/staple removal
Appropriate wound care: wound vac

Employee Information Form

TB Questionnaire

Competency Skills Checklist for Home Care Nurses

Agreements Section

Policy and Procedure Agreement

Infection Control

Employee Acknowledgement of Handbook

Job Acceptance Statement

AGREEMENT TO ARBITRATE EMPLOYMENT CLAIMS

COVID-19 Vaccine Policy and Procedures

Agreement for E-Verify

In-service Documentation:

Other Agreements

Competency Exam

Orientation Checklist

	Competent	Never Done	Needs Review
Demonstrates knowledge of basic principles/ utilization: T- tube
Demonstrates knowledge of basic principles/ utilization: Jackson-Pratt
Demonstrates knowledge of basic principles/ utilization: chest tube
Demonstrates knowledge of basic principles/ utilization: nasogastric tube
Demonstrates knowledge of basic principles/ utilization: closed wound suction
Demonstrates knowledge of basic principles/ utilization: pulse oximeter
Demonstrates knowledge of basic principles/ utilization: glucometers

	Competent	Never Done	Needs Review
Demonstrates knowledge related to death and dying in the home: proper documentation
Demonstrates knowledge related to death and dying in the home: notification of physician
Demonstrates knowledge related to death and dying in the home: notification of funeral home
Demonstrates knowledge related to death and dying in the home: post-mortem care
Understand policy/procedure: code status
Understand policy/procedure: DNR

	Competent	Never Done	Needs Review
Airway maintenance: oral airway
Airway maintenance: nasal airway
Ambu-bag
Oxygen therapy: Mask/Venti mask
Oxygen therapy: nasal cannula
Airway maintenance: tracheostomy tube
Airway maintenance: CPAP/BiPAP
Suctioning: oropharyngeal
Suctioning: nasoparyngeal
Tracheostomy: Shiley/Bivona
Tracheostomy care

	Competent	Never Done	Needs Review
Place/maintain: straight urinary catherization
Place/maintain: indwelling catheter
Indwelling catheter: insertion
Indwelling catheter: irrigation
Indwelling catheter: collection of urine specimen
Suprapubic
Urostomy
Colostomy: routine care/pouching
Colostomy: skin care
Colostomy: irrigation
Colostomy: patient teaching
Enemas

	Competent	Never Done	Needs Review
Active/ passive exercise
Special care mattress
Special care beds
Restraints policy
Transfer technique
Skin/ decubitus care
Implements isolation and uses standard precautions

	Competent	Never Done	Needs Review
Documents physician verbal orders
Communicates new orders to other nurses/ agency

	Number it 1 - 3
Call parent or 911
Check pulse ox for correlation = heart rate, assess patient for s/s of respiratory distress
Suction patient if available, turn up O2, check for equipment malfunction

	Received
Chain of Command
Agency Services
Mission, Goals, and Philosophy Statement
Patient Rights & Responsibilities
Complaints and Grievances
Public Disclosure

	Received
Employee Handbook
Acknowledgment of Employee Handbook (Sign and Return)
Drug, and Alcohol abuse (Sign and Return)
Employee Supervision & Continuing Education Requirements
Inventory Checklist (Sign and Return)
Professional Agreement Addendum (Sign and Return)
Policy and Procedure Manual Agreement (Sign and Return)
Performance Evaluations (Skills Checklist )
Agreement to Arbitrate Employment (Sign and Return)
Conditions of Employment (Sign and Return)
Direct Deposit Form (Sign and Return)
Confidentiality Agreement (Sign and Return)

	Received
Coverage Map
Office Policy and Procedural Manual
Fax Cover Sheet
Intake Referral Sheet
Visit Time Sheet
Complaint Form
Release of Information
Release of Information Authorization

	Received
New Admit Packet Part A
Chart Organization

	Received
Infection Control Policies and Procedures
Blood-Borne Pathogens
Exposure Report (Sign and Return)
Hepatitis B Training
Hepatitis B Declination (If Hepatitis is declined Sign and Return)
Tuberculosis
MRSA
Spills in the Home
Maintaining Equipment in the Car
Equipment Cleaning
Home Care Bag Procedures

	Received
Nursing Policy and Procedural Manual
OASIS Training
Professional Boundaries
Performance Improvement Plan
Abbreviations
Documentation Rules
Nurses Documentation Bible
Missed Visit Report
Physician Telephone Orders
Communication
Wound Care Form
HHA Care Plan
60 Day Summary
Case Conference
MAR
POC COP
HHA COP
CR COP
SN COP

	Received
Office P&P
Nursing P&P
Drug Guide
ICD-9 Coding
Equipment
Available Community Resources

	Received
Fire Extinguisher Locations and Usage
MSDS Manual Location
Eye Wash Station Location
Safety
Reporting Emergencies
Fire Safety