New Hire Packet - Advanced Travel Therapy

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ADVANCED FAMILY OF BRANDS
New Employee Packet Document Checklist
Welcome aboard! We are excited that you have chosen Advanced to serve you! Please complete all
the items listed below and submit them in order to be ready to begin your first assignment. At the end
of this checklist is information on how you can submit your documents either by email, fax, or by
mailing it via a traceable method.
Please submit copies of the following documents:
 All current Professional Licenses
 American Heart Assoc. Healthcare Provider BLS/CPR
 NBCOT cert. (OT’s) or ASHA cert. (SLP’s)
 Driver’s License
 Social Security Card
 Proof of 2 MMR Vaccines or Positive Titer
 TB Test w/in last year OR Chest X-ray w/in last 5 yrs. (must also submit proof of a positive TB
Test to support x-ray) – ** Helpful Hint!: We strongly advise a 2 Step TB Test as many of our
clients require this. See TB Test form for additional info.
 Physical Examination w/in last 1 year
We will also need the following forms completed and submitted with the copies listed above. These
forms are all part of our New Employee Packet which is available online through our website
http://www.advanced-medical.net/nhp/
Please complete, sign, date, and submit each of these forms:
 Employment Application/License &
 Job Description
Certifications form
 Background Authorization Form
 JCAHO & Traveler Handbook
 Tuberculosis Test Record Form
Acknowledgement
 Hepatitis B Vaccinations & Varicella Form
 Physical Affidavit
A Quality Assurance Representative will contact you regarding Drug Screening information once you
have accepted an assignment. Please don’t hesitate to contact the Quality Assurance (QA) Department
if you have any questions regarding your New Employee Packet documentation. You can reach the QA
Department at 888-265-2680 or if you know the name of the QA representative you have been in
contact with, you can also email them at: [email protected]
Thank you,
The Quality Assurance Department
Advanced Medical Personnel Services  5535 S. Williamson Blvd, Suite 774  Port Orange, FL 32128
Phone 888-265-2680  Fax 386.944.7202  http://www.advanced-medical.net/NHP.html
Employment Application
Personal Information:
First Name:
Middle Initial:
Last Name:
Social Security Number:
Date of Birth:
Permanent Address:
City:
State:
Zip:
Hm Phone#:
Fax#:
Cell Phone#:
Email:
Temporary Address:
City:
State:
Zip:
Emergency Contact Name:
Emergency Contact Phone:
Relationship:
Human Resources:
How did you hear of
Advanced?
Referral Name:
Are you currently a U.S. Citizen or permanent resident?
YES
NO
Have you ever been convicted of a crime, other than a minor traffic violation?
If yes, please explain:
Have you ever worked with Advanced in the past? YES
YES
NO
Education: (Please attach your Resume)
School Name:
Location:
Graduation Date:
Diploma/Degree/Certifications:
Graduation Date:
Diploma/Degree/Certifications:
Additional Certifications:
Continuing Education in
the last two years:
Professional Information: (Please attach a photocopy of all licenses)
Classification:
Specialty(s):
Years Experience:
Application Page 1 of 3
Advanced  5535 S. Williamson Blvd, Suite 774  Port Orange, FL 32128
Phone 800.330.7711  Fax 386.944.7202  http://www.advanced-medical.net/NHP.html
NO
Has any of your Professional License(s) ever been investigated or suspended? YES
If yes, please explain:
Desired position: TRAVEL
DIRECT HIRE
NO
Date Available: _____/_____/______
Travel Location Preferences:
License and Professional Certifications
Specialty (circle one):
All Active Licenses:
State:
PT
OT
SLP
COTA
License #:
PTA
RN
Issue Date:
ST
CF/CFY
Expiration Date:
Active Certifications:
ASHA#:
EXPIRATION:
FSBPT#:
EXPIRATION:
NBCOT#:
EXPIRATION:
OTHER:
EXPIRATION:
ACLS
EXPIRATION:
OTHER:
EXPIRATION:
BLS
EXPIRATION:
OTHER:
EXPIRATION:
NRP
EXPIRATION:
OTHER:
EXPIRATION:
Pending License:
State:
Application Date:
Application Receipt Verified?
Board Contact Info:
(Initial)________I confirm that the information in this application is true and correct to the best of my
knowledge. That providing incomplete or false information can result in my disqualification for
employment and can also violate State Laws. I grant permission to Advanced to inquire & research any
current/pending licensure. I hereby authorize Advanced to thoroughly investigate my references, work
record, education, background check, state board information and any other matters related to my
qualification for employment.
_________________________________________________
______________________________
Employee Signature
Date
Release Authorization for Background Inquiry
In connection with your application for employment (including contract for services), with Advanced
you understand that consumer reports or investigative reports may be requested about you including
information about your character, general reputation, personal characteristics and verification of
employment record, education, qualifications, criminal record, inquires regarding driving record and
credentials. This process may involve a search of public records or various Federal, State, or Local
agencies. Reports containing injury and/or medical information may be obtained after a tentative offer
of employment has been made.
You hereby authorize Advanced to obtain such consumer reports and investigative consumer reports,
verifications, and inquires and any other company with which they contract for your services. By
signing below, you hereby authorize without reservation, any party or agency contacted by this
employer, or the consumer reporting agency acting on behalf of the employer, to furnish the above
mentioned information. You further authorize ongoing procurement of the above mentioned reports
at any time during your employment or contract for services. You also agree that a fax, e-mail or
photocopy of this authorization with your signature shall be accepted with the same authority as the
original.
Printed Name:
Date of Birth:
*If born in the US, please list in which state, or if you were not
born in the US, please list your country of birth:
Social Security #:
Driver’s License State:
Driver’s License #:
Driver’s License Expiration:
Current Address:
_________________________________________________
______________________________
Employee Signature
Date
Hepatitis B Vaccination
OSHA requires that all health care workers get the opportunity to have the Hepatitis B vaccination
offered to them by their employer. Please check the box next to one of the following statements that
best applies to you and your decision regarding the Hepatitis B vaccine.
________ 1. I understand the OSHA guidelines and I still need # __________ or booster in the series. I
will make arrangements with AMPS to receive this dose of the vaccine series.
________ 2. I understand the OSHA guidelines and I decline because I have already completed the
Hepatitis B Vaccination Series.
________ 3. I understand the OSHA guidelines and I have declined. I am not interested in having the
Hepatitis B vaccination series.
Varicella (Chickenpox) History
In following the CDC Guidelines, health care workers are required to have either a reliable history of
Varicella, two vaccines 4-8 weeks apart or an existing titer showing immunity. Please indicate below
what is applicable in your case:
________ I have had (Chickenpox) Varicella disease as a child
________ I have had the Varicella Vaccines (please attach/fax records for proof)
________ I have had Positive Varicella Titers (please attach/fax records for proof)
_________________________________________________
______________________________
Employee Signature
Date
JCAHO/OSHA/HIPAA
I have read and understand the information provided by Advanced on the following
website: http://www.advancedmedical.net/nhpdocs/jcaho/Health_Prof_Guidelines_OSHA_JCAHO_HIPPA.pdf
HIPAA
Age Specific
Child and Elder Abuse
Emergency Management Preparedness
Environmental Safety
Body Mechanics
Fire Safety
Hazardous Chemicals
Infection Control and Blood-borne Pathogens
TB Education
National Patient Safety Goals for 2014
Cultural Diversity
Patient Bill of Rights
Ethics of Care
_______________________________________
Employee Signature
_____________________________
Date
Traveler Handbook Receipt of Acknowledgement
I have read and understand the information I was given regarding Advanced’s Policies
and Procedures for travelling therapists on the following website: http://www.advancedmedical.net/nhpdocs/jcaho/Traveler-Handbook.pdf
Employee Signature
Date
Health Statement – Physical Record
_________________________________________________
______________________________
Name of Physician
Date
_________________________________________________
______________________________
Name of Patient (Please Print!!)
Job Title
_________________________________________________
______________________________
Signature of Patient / Social Security #
Phone #
 Fit to Work/No Restrictions
 No Communicable Diseases
 Restrictions – see comments section below
Physician’s Statement: I examined the individual named above, and to the best of my knowledge,
he/she is physically and medically qualified to perform the essential functions of the above referenced
means of employment and has no health condition, including any communicable diseases, which
would create a direct threat to patients.
Comments:
Office Address:
Office Tele #:
_________________________________________________
______________________________
Physician’s Signature
Date
Phone 800.330.7711  Fax 386.944.7202 http://www.advanced-medical.net/NHP.html
Tuberculosis Test Record
Name: _______________________________________________________
Please Print Clearly
TB Step One
Address:
Date Placed:
__________________
Signature: ____________________
Address:
Date Read:
__________________
Results:
______________ mm
Signature: ____________________
Negative
Positive (circle one)
**Note: If a two-step is required, the 2nd test cannot be placed any sooner than 8 days
after the 1st Read date**
TB Step Two
Address:
Date Placed:
__________________
Signature: ____________________
Address:
Date Read:
Results:
__________________
______________ mm
Signature: ____________________
Negative
Positive (circle one)
*For any positive results, please send a copy of your most recent chest X-Ray and complete the information below.
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Positive Tuberculosis History
Exam Results:
Office Address:
Office Tele #:
Chest X-Ray Date: ____________________ Doctor’s Signature: ________________________________
Have you experienced any of the following?
1. Chronic (recurring) cough?
Yes No
5. Unexpected weight loss?
Yes
No
2. Unexplained recent fevers?
Yes No
6. Unexplained chronic fatigue?
Yes
No
3. Current Night Sweats?
Yes No
7. Been advised that you are
Yes
No
4. Coughed or spit up blood?
Yes No
immunosuppressed for any reason?
The above statements and answers are true to the best of my knowledge.
Employee Signature: ___________________________________ Date: _________________________
Advanced 5535 S. Williamson Blvd, Suite 774  Port Orange, FL 32128
TB Definition and Verification
TB Test - True Two Step



1st placed, then read within 48 to 72 hours
2nd placed within 8 to 21 days after the 1st one is read ( this means to start counting days the
day after the test was read )
2nd read within 48 to 72 hours
Once a true two step is completed, an annual TB Test is required. The years must be consecutive, and
you have 30 days from the read date of the previous year. If a year is missed, then the process of a true
two step must be started over.
Thank you,
Quality Assurance Department
Phone: 888-265-2680
Fax: 386-944-7202
[email protected]
Advanced 5535 S. Williamson Blvd, Suite 774  Port Orange, FL 32128

New Hire Packet - Advanced Travel Therapy

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