36C25819Q0096-011.doc

VENDOR ACCESS CHECKLIST

SOUTHERN ARIZONA VA HEALTHCARE SYSTEM

Vendor Representative’s Name:

Company:

Address:

Telephone Number:

Email Address:

Type of Supplies/Services Marketed:

Vendor Signature: __________________________ Date Submitted: __________________

REQUIRED DOCUMENTATION:

Documentation stating no active pulmonary disease OR negative Tuberculosis (TB) Skin Test Documentation

Record of Measles, Mumps and Rubella (MMR) Immunization OR Positive Titer Results

Record of Influenza Vaccination during Influenza season (Sept – March) * Statement of Compliance (Attachment A)

Confidentiality Agreement (Attachment B) Certificate of Completion of Annual Privacy Training- VA 10203

____ Certificate of Completion of VA Privacy and Information Security Awareness and Rules of Behavior- VA 10176 ADDITIONAL DOCUMENTATION REQUIRED IF REPRESENTATIVE WILL HAVE ACCESS TO CLINICAL, SURGICAL OR INVASIVE PROCEDURES:

Procedural Area Rules of Conduct (Attachment C)

Procedural Area Acknowledgement of Training and Potential Risks and Hazards (Attachment D)

Evidence of Insurance Coverage for Liability ($1,000,000)

Verifiable Company Documentation of Specific Vendor Representative Competencies for Procedures/Equipment Date Verified: ________________ Vendor Liaison Signature: _________________________