J-9_Updated_03.24.16.pdf

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Medical Staffing Services
Solicitation number
HSCEDM-16-R-0002
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J-9 Updated

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J‐9 ‐ DOCUMENT CHECKLIST

Personnel Documents

Document Title Credentialing Documents

Privileged (LIP)

Privileging Documents

Ad m in is tr at iv e As si st an t

M ed ic al R ec or ds T ec h

N ur se P ra ct iti on er s

Ph ys ic ia n As si st an t

Re gi st er ed

N ur se s

LV

N L

PN

C M A C.

N .A

Ra di ol og y Te ch ni ci an

Ph ar m ac is t

Ph ar m ac y Te ch ni ci an

D en ta l A ss is ta nt

D en ta l H yg ie ni st

Al l P hy si ci an s

Ps yc hi at ris t

Ps yc ho lo gi st

D en tis t

So ci al W or ke r

Section I ‐ Privileges Application for Privileges X X X X X IHSC Privilege Letter X X X X X Peer Review X X X X X X X X X Statement of Health and Ability X X X X X X X X X X X X X X X X Statement of Confidentiality X X X X X X X X X X X X X X X X Ackn of Policy Understanding (local, national, residential standards) X X X X X X X X X X X X X X X X Statement of Risk and Responsibility X X X X X X X X X X X X X X X X Malpractice Insurance X X X X X X X X X X X X X X Release of Information X X X X X X X X X X X X X X X X

Section II ‐ Education Professional School Diploma (primary source verified) X X X X X X X X X X X X X X Internship / Residency Documents/Preceptor Documents X X Professional License / Certification (primary source verified) X X X X X X X X X X X X X X Board Certification X X X X National Practitioner Database X X X X X AHA Heartsaver® CPR AED or BLS for Healthcare Providers® Certification X X X X X X X X X X X X X X X X

Section III ‐ Experience and Current Competency HSD‐500 Facility Orientation Checklist X X X X X X X X X X X X X X X X Scope of Practice X X X X X X X X Competency Checklist X X X X X X X X X X X

Section IV ‐ Professional Information Position Description (signed) X X X X X X X X X X X X X X X X Evaluations X X X X X X X X X X X X X X X X CV/Resume X X X X X X X X X X X X X X X X Personnel Actions (Awards/Letters of Appreciation/Letters of Counseling) X X X X X X X X X X X X X X X X Emergency Contact X X X X X X X X X X X X X X X X

J‐9 ‐ DOCUMENT CHECKLIST

Employee Health Record / Leave File

Ad m in is tr at iv e As si st an t

M ed ic al R ec or ds T ec h

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Ph ys ic ia n As si st an t

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C M A C.

N .A

Ra di ol og y Te ch ni ci an

Ph ar m ac is t

Ph ar m ac y Te ch ni ci an

D en ta l A ss is ta l H yg ie hy si ci an s

Ps yc hi at ris t

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D en tis t

So ci al W or ke r

Section I ‐ TB Screening/Fit Testing TB Screening X X X X X X X X X X X X X X X X Respirator fit test results X X X X X X X X X X X X X X X X Respirator Medical Clearance X X X X X X X X X X X X X X X X Blood borne pathogen exposure documentation X X X X X X X X X X X X X X X X

Section II ‐ Vaccination Records Influenza X X X X X X X X X X X X X X X X Vaccine Records/ Immunity Status (MMR, Hep B, Hep A, Varicella) X X X X X X X X X X X X X X X X

Section III ‐ General Medical Records Ishihara Colour Deficiency Test X X X X X OSHA 301/ Incident Reports X X X X X X X X X X X X X X X X Medical Waivers/ADA Accomodations X X X X X X X X X X X X X X X X Misc ‐ Progress Notes; Bloodborne Pathogen Exposure Documentation X X X X X X X X X X X X X X X X

Section IV ‐ Annual Leave Vendor Leave Forms X X X X X X X X X X Leave Related Medical Documentation X X X X X X X X X X X X X X X X

J‐9 Document Checklist

Training File

Ad m in is tr at iv e As si st an t

M ed ic al R ec or ds T ec h

N ur se P ra ct iti on er s

Ph ys ic ia n As si st an t

Re gi st er ed

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N .A

Ra di ol og y Te ch ni ci an

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Ph ar m ac y Te ch ni ci an

D en ta l A ss is ta l H yg ie hy si ci an s

Ps yc hi at ris t

Ps yc ho lo gi st

D en tis t

So ci al W or ke r

Section I ‐ Annual In‐House Training In‐services Certificates of Completion X X X X X X X X X X X X X X X X Post‐Tests/Self‐Study Modules X X X X X X X X X X X X X X X X

Section II ‐ Virtual University Certificates X X X X X X X X X X X X X X X X

Section III ‐ CEUs Documentation X X X X X X X X X X X X X X X X

Section IV ‐ Miscellaneous Training Documents Vendor policy ‐ Standards of Conduct (signed) X X X X X X X X X X X X X X X X Miscellaneous Documents X X X X X X X X X X X X X X X X

J-9 - Document Checklist Page 1
J-9 - Document Checklist-Page 2
J-9 - Document Checklist- Page 3

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