Memorandum
From:
Director, Research Staffing Section (151)
Subj:
ACTION REQUESTED: VA Research WOC Renewal Packet
To:
WOC Renewal Applicant
Hello,
It is time to renew your WOC appointment with Research Service. You are receiving this notice
approximately 60 days in advance of your WOC appointment expiration date. Your action is requested to
respond to this notice as quickly as possible to avoid delays in the renewal of your appointment
Research Staffing Section must have this packet at least 2 weeks prior to your VA Badge
expiration date in order to allow sufficient time to process your renewal.
Your Research WOC appointment must remain current in order to continue working for the VA Research
Department. You are NOT authorized to work in the Research Department should you allow your WOC
appointment to expire.
Please fill this packet out on the computer to ensure it is legible.
ACTION ITEMS ASSOCIATED WITH THIS PACKET:
¾ Your Principal Investigators (PI/ Supervisor) signature or initials are required on a few of these
pages. Those fields are highlighted in blue.
¾ Your signature or initials are required on a few of these pages. Those fields are highlighted in
yellow.
¾ Employee Health must sign off on the TB (Tuberculosis Surveillance) screening page BEFORE
you turn your renewal packet in. Please note: You may need to get a new PPD screening test if
you have not had one in the last year.
¾ You must be fingerprinted PRIOR to submitting your packet in order to allow time for this to clear
for your badge to be issued. Although you may have been fingerprinted for your current
appointment, VA now requires fingerprinting EACH time a badge is issued.
¾ If you are currently renewing a 6 month appointment, please contact Robert or Debbie to
schedule an appointment to initiate a background investigation
If you are not planning to renew your WOC appointment, please ensure that your badge is returned to our
office, either by mail or dropped off, on your last day of work.
Thank you,
Coral Ana,
Research Staffing Section Supervisor
Research Staffing Section Points of Contact:
• Robert Atienza, Staffing Intake Coordinator: 858-552-8585 x1159 / roberto.atienza@va.gov
• Debbie Lynn, Compliance Associate: 858-552-8585 x2505 / deborah.s.lynn@va.gov
• Coral Ana, Research Staffing Supervisor: 858-552-8585 x5980 / coralyn.ana@va.gov
DEPARTMENT OF VETERANS AFFAIRS VA San Diego Health Care System 3350 La Jolla Village Dr. San Diego, CA 92161
WOC Employee Contact and Work Information
Please ask your Principal Investigator to assist you in completing this page
Date:
Research Staff Name:________________________
PI:______________________________________
PIace of Birth:
Date of Birth:
Position Title:
Paid by:
Service:
UCSD
VMRF
Other):
Mail Code:
Room #:
SSN#:
Work Email (if none, please provide personal email address):
Lab Phone:
Office Phone:
Home Phone:
Home Address:
Mailing Address
City
State
Zip
---------------------------------------------------------------------------------------------------------------------------------------------------------Work Schedule:
Full-time (40 hours)
Work Days:
S
Part-time (
M
T
W
hours)
Th
F
Student:
S
Y
N
AM to
Work Hours:
PM
Transportation Method: (i.e., car, carpool, coaster, bus, etc.)
Please be advised that parking is limited at the VA and you may not qualify for parking privileges at the VA.
---------------------------------------------------------------------------------------------------------------------------------------------------------Are you a licensed healthcare provider:
Yes (please provide photocopy)
No
Expiration Date:
License #:
---------------------------------------------------------------------------------------------------------------------------------------------------------How long do you plan to work in this position?
6 Months
1 Year
2 Years
----------------------------------------------------------------------------------------------------------------------------------------------------------
I understand that (1) this employee will not begin work until all paperwork has been approved; (2) that I am responsible
for notifying Research Admin when this WOC employee terminates; and (3) that this WOC employee will complete all of
the necessary training to complete his/her duties that he/she has been assigned and that documentation is submitted
to Research Admin office and all training remains current.
P.I. Signature
Date
PLEASE CHECK A JOB TITLE THAT BEST
DESCRIBES YOUR WORK AT THE VA.
Date:
Research Staff Name:
PI:
Co-Investigator:
**NOTE: ALL CLERICAL POSITIONS ARE TITLED**
“RESEARCH ASSISTANT”
List of Position Duties
Biological Science Aide
Research Biologist/Biologist
Biological Science Lab Technician
Research Biomedical Engineer
Biomedical Engineer
Research Chemist
Biomedical Technician
Research Health Science Specialist
Research Assistant**
Research Health Scientist
Clinical Nurse Specialist
Research Microbiologist
Clinical Research Psychologist
Research Pharmacologist
Computer Programmer
Research Physiologist
Computer Programmer Analyst
Research Psychologist
Computer Scientist
Research Speech Pathologist
Electronics Technician
Statistician
Social Science Technician
Research Pharmacist
Nurse Researcher
Veterinarian
Physical Science Technician
Psychologist
Psychology Aide
Psychology Technician
Clinical Research Assistant
Maintenance
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Scope of Practice for Research for NON-PI
Renewal
Name:
Research Job Title:
Email Address:
Phone:
Principal Investigator (PI): ____________________________
Primary Supervisor (if not PI): ____________________________
Additional supervising PIs or alternate supervisors with same VA clinical privileges as PI: _______________________ /
EDUCATION
Education
Undergraduate
Graduate
Doctoral
Degree
Institution
Degree Field
Specialty
Clinical License #: _________________ State: __________ Country: ___________________
Discipline of License :
*Psychology Only:
MD
Nursing
Psychology
Resp. Therapy
Social Work
N/A
Date Rcvd (Or Projected)
Not Applicable
Other: _____________
APA-accredited PhD Program
APA-accredited Internship – Institution:___________________
Training Program
Requests for Appointment in this category must be accompanied by TQCVL or RCVL list confirmation
Participating in a Formal Clinical Training Program through the VA (managed by Education Service)?
No
Yes
Start Date: _________ Planned Date of Completion: __________ Supervisor (if other than PI): _____________________
CLINICAL TRAINING PROGRAM (check one):
Medical Student
Student Resident
Clinical MS/PhD Post-Doctoral Trainee
Clinical MS/PhD Student
Fellow
Other (specify): ________________
The Scope of Practice is specific to the duties and responsibilities of research personnel as an agent of the listed Principal Investigator
(PI) and/or alternate supervisor. As such he/she is specifically authorized to conduct research with the responsibilities outlined below.
The supervisor must complete, sign and date this Scope of Practice. Research staff performing clinical care as part of research or
performing research activities that may be considered clinical care must also be credentialed and privileged or have a scope of practice
validated through a clinical service.
PI Not
Approved
PI
Approved
NATURE OF DUTY
Staff
Requested
RESEARCH PROCEDURES: Research staff may be authorized to perform the following duties/procedures on a regular and ongoing
basis. Research staff should initial boxes to identify and request specific job duties where appropriate. PI must initial where job duty is
approved or denied. Research staff (employee) and PI initials indicate they are aware and agree to maintain current status of
role-specific training as itemized below, and that Human, Animal, or Bench Research duties may ONLY be performed on
active Human, Animal, or Bench Protocols with current approval by the VASDHS R&D Committee and applicable
Subcommittee(s).
ACOS R&D Approval
Special Conditions
YES
NO
Research Preparatory Duties: Does Not Require Employee to Be on Active Protocol/Project Staff List
Not Requested
Initiates submission of regulatory documents to IRB,
IACUC, VA R&D committee and others (VMRF, FDA,
IRC, etc).
Page 1 of 5
PI Not
Approved
PI
Approved
NATURE OF DUTY
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Staff
Requested
VA San Diego Healthcare System (664)
ACOS R&D Approval
Special Conditions
YES
NO
Human Subjects Research Duties: Performed ONLY on Active VASDHS Human Subjects Protocol on which
Employee is Listed as Staff
Not Requested
Accesses, records, or analyzes sensitive subject
information while maintaining confidentiality.
Maintains complete and accurate data collection for
case report forms and source documents
(Non-subject contact) – requires HRPP & GCP,
Privacy & HIPAA Training
Provides education regarding study activities, or
provides screening forms or documents to subjects
and assists in completion without performing
assessment activity. (Subject contact) – requires
HRPP & GCP, Privacy & HIPAA, and Suicide
Prevention Training
Obtains informed consent from research subject,
documents consent in research subject’s medical
record if applicable. (Subject contact) – requires
HRPP & GCP, Privacy & HIPAA, and Suicide
Prevention Training
Documents study activities in CPRS– requires
HRPP & GCP, Privacy & HIPAA Training
Provides education and instruction of study
medication use, administration, storage, and side
effects, and notifies appropriate parties regarding
adverse drug reactions– requires HRPP & GCP,
Privacy/HIPAA, and Suicide Prevention Training
Schedules subjects using VistA or CPRS –requires
VistA Scheduler training
Performs venipuncture to obtain specimens required
by study protocol * Attach phlebotomy certificate*
(VA privileged clinicians do NOTselect this duty,
request Clinical Intervention Duty below). –
requires HRPP & GCP, Privacy & HIPAA, &
Suicide Prevention Training
Administers questionnaires, surveys, Mental Health
instruments, or other assessment tools without
clinical interpretation, diagnosis, intervention, or
treatment. – requires HRPP & GCP, Privacy &
HIPAA, and Suicide Prevention Training
Clinical Interventions Including Diagnosis, Interpretation, or Treatment: Performed ONLY on Active VASDHS
Human Subjects Protocol on which Employee is Listed as Staff
Not Requested
Full (not limited) clinical privileges or functional statement/clinical scope of practice required from appropriate clinical service. If clinical
service has granted only limited privileges, then do not select Clinical Intervention Duty below, instead use “other duties” on next page
to specify what limited clinical duties are being requested. Research Service does not approve clinical privileges but will confirm
existing privileges prior to approving any duties in this category.
Physician-Specific
Nursing-Specific
Psychology-Specific
Other: Describe
Page 2 of 5
PI Not
Approved
PI
Approved
NATURE OF DUTY
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Staff
Requested
VA San Diego Healthcare System (664)
ACOS R&D Approval
Special Conditions
YES
NO
Animal Research Duties: Performed ONLY on Active VASDHS Animal Subjects Protocol on which Employee is
Listed as Staff
Not Requested
Animal Care, procedures, or surgery
(as described on attached form) – requires
Biosecurity, Biosafety, VMU Orientation, Working
with the VA IACUC, and if applicable Waste
Anesthetic Gases and species specific training
designated by assigned protocol.
Laboratory Bench Research Duties: Performed ONLY on Active VASDHS R&D Project with Bench Research
Component on which Employee is Listed as Staff
Not Requested
Bench Research duties (specify on attached form)
– requires Biosafety and Biosecurity Training
Works with de-identified human specimens (does
NOT require HRPP & GCP training)
Works with identifiable human specimens – requires
HRPP & GCP, Privacy & HIPAA Training
TO BE COMPLETED BY THE RESEARCH ADMIN OFFICE:
Required Role Specific Training for ANY Human Subject Duties or Human Specimens:
VA Human Subjects Protection and Good Clinical Practices (HRPP & GCP)
Required Additional Training for Human Subjects Contact Duties:
Suicide Prevention
Required Additional Training for Patient Scheduling Duties:
VHA Scheduling, Electronic Wait List (EWL)
Required Training for Animal Research Duties:
VMU Animal Orientation
Working with the VA IACUC
Waste Anesthetic Gases (WAG)
Required Training for Laboratory Bench Work:
Biosecurity
Biosafety
Signature of Research Staff (employee)
PI Not
Approved
PI
Approved
Mr./ Ms.
is authorized to perform the following miscellaneous
duties not otherwise specified in this Scope of
Practice.
Staff
Requested
OTHER DUTIES (describe): ACOS R&D to Note Under Special Conditions If Duty Requires Employee to Be on
Staff List of Active Protocol/Project
Not Requested
ACOS R&D Approval
Special Conditions
YES
NO
Date
Page 3 of 5
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
PRINCIPAL INVESTIGATOR STATEMENT:
This research Scope of Practice was reviewed and discussed with __________________________ on_____________.
After reviewing education, competencies, qualifications, research practice involving human subjects, and individual skills
as appropriate, I certify that he/she possesses the skills to safely perform the aforementioned duties/procedures. I am
familiar with all duties/procedures granted to this employee in this Scope of Practice. The research staff (employee) and I
agree to abide by the parameters of this Scope of Practice, all-applicable hospital policies and research related
regulations.
I understand that (1) this employee will not begin work until all paperwork has been approved and the employee has
been added to appropriate protocol/project staff lists as applicable to the category(s) of duties; (2) that I am
responsible for notifying Research Admin Office when this employee terminates, (3) that this employee will receive all of
the necessary training to complete his/her duties that he/she has been assigned and that documentation is on file in my
office and copies submitted to Research Admin Office, and (4) I will ensure this employee completes all recurring training
requirements prior to required renewal dates and will monitor their training status.
Principal Investigator/ Supervisor
Date
CLINICAL SERVICE APPROVAL (applicable if clinical duties requested on Research Scope of Practice)
Licensed Practitioners Operating under Approved Privileges (Medical Staff Office):
Full Clinical Privileges (check appropriate boxÆ):
Already Privileged
In Process
Limited Clinical Privileges (check appropriate box Æ & identify Responsible Clinician):
Already Privileged
In Process
ÆResponsible Privileged Clinician who will review/monitor/co-sign all clinical activities:____________________________
Licensed Clinical Staff Operating under Clinical Scope of Practice/Functional Statement:
Full Authority to Act Under License/Scope Issued by Clinical Service (check appropriate Æ):
Approved
In Process
Limited Authority to Act Under License/Scope Issued by Clinical Service (check appropriate Æ):
Approved
In Process
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ______________________________
Unlicensed Staff/Trainees Permitted Limited Clinical Duties Under Supervision:
Unlicensed Professional working towards licensure (as permitted by specific VHA Policy and/or VASDHS Medical Center Policy)
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ____________________________
Trainee on RCVL or TQCVL List (processed as trainee through Education Service)
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ____________________________
Not authorized for clinical duties at VASDHS: Research Scope of Practice must not include duties requiring licensure or Clinical
Scope of Practice, and ID Badge / lab coat must not imply clinical credentials
Signature of Clinical Service / Section Chief
Date
Name of Service / Section
I have discussed my role with the Clinical Service Chief and agree to take responsibility for review and sign-off of all clinical
interventions by this employee.
Responsible clinician concurrence signature:
Not Applicable
============================================================================================
Page 4 of 5
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Research Admin OFFICE USE ONLY:
Eligible for licensure by education and training
Yes
No
Education Verification
Yes/Valid Thru: ________
No
Not Applicable
Privileges or License Verification
Yes/Valid Thru: ________
No
Not Applicable
Clinical Training Program Confirmation (RCVL or TQCVL)
Yes/Valid Thru: ________
No
Not Applicable
Program: ___________________________
Research Admin Office Review
Date
============================================================================================
Associate Chief of Staff R&D Review:
Approved (check as appropriate below for any conditions of approval)
Current Clinical Privileges must be maintained at all times (attach copy of privileges to this scope)
Current Credentialing as a Non-LIP must be maintained at all times (attach copy of current appointment)
Current Clinical License must be maintained at all times (attach copy of clinical license to this scope)
Current Certification of Competency must be on file and attached to this scope
Verification of Education required (attach evidence of completion to this scope)
Must maintain active trainee status with VASDHS Education Service to perform clinical duties permitted on this
Research Scope; termination of trainee status would require issuance of privileges in order to maintain clinical
duties
Limited Privileges or Limited Clinical Scope of Practice requires review and co-signature of all clinical
assessments, diagnosis, treatment, or intervention by Responsible Clinician identified by Clinical Service Chief on
prior page
Limited authority to function as Unlicensed Professional working towards clinical licensure under
Medical Center Policy; requires review and co-signature of all clinical assessments, diagnosis, treatment, or
intervention by Responsible Clinician identified by Clinical Service Chief on prior page
Licensed Professional hired to fulfill duties that do not require licensure/privileges; per communication from Office
of Quality and Safety, Director of Credentialing and Privileging, dated April 22, 2012, VetPro Credentialing is NOT
required. Employee MUST NOT present to subjects as a licensed, certified, or privileged clinician,
and MUST NOT wear lab coat or ID badge indicating clinical training
Foreign Medical Graduate, does not require VetPro Credentialing but MUST NOT present to subjects as a
clinician, and MUST NOT wear lab coat or ID badge indicating clinical training
Not authorized to perform ANY duties that require clinical licensure, privileges, or certification;
Other (specify): ______________________________________________________________________________
Approved pending VetPro Credentialing:
As Licensed Independent Practitioner (LIP) through Medical Staff Office
Full Clinical Privileges as indicated by Clinical Service/Section Chief Above
Limited Clinical Privileges as indicated by Clinical Service/Section Chief; any clinical duties listed on this
Research Scope require monitoring and sign-off by responsible clinician specified above.
As non-LIP through Human Resources
Full Authority to work under Clinical Scope of Practice as non-LIP as indicated by Clinical Service Chief
above.
Limited Authority to perform duties specified on this Research Scope of Practice as non-LIP as indicated
by Clinical Service Chief above; any clinical duties listed on this Research Scope require
monitoring and sign-off by responsible clinician specified above.
Disapproved (state reason) __________________________________________________________________________________
Identify frequency of Scope Review if required by ACOS R&D:
Annual Scope Review--Scope Includes Clinical Duties
Review by ____________________
Date
(projected change in clinical status requires review earlier than annual)
Subject to 10% Annual Quality Assurance Review of Scopes with non-clinical Human Subjects Research duties
Not Applicable: Scope does not include ANY Human Subjects Research duties
Gerhard Schulteis, PhD.
ACOS R&D
Date
Page 5 of 5
IN CASE OF A MEDICAL EMERGENCY
WHAT TO DO IF YOU ARE INJURED ON VA PROPERTY
1. In case of a medical emergency involving respiratory distress or unconsciousness here in the VA San Diego
Healthcare System (VASDHS), have someone call x3333 and report a Code Blue. For all other medical
emergencies requiring assistance call the Emergency Department at x3386.
2. Immediately report the injury to the principal investigator, office manager, or co-worker.
3. If you are able to walk, but need medical assistance, proceed to Employee Health on the 1st floor, room #
1211 and be seen by the doctor. Follow all instructions given to you by Employee Health.
4. If you elect to see your own doctor, get the proper forms from nurse in employee health and follow the
instructions.
5. If you are a VA Paid Employee, as soon as you are able, see Yolanda Castro in Research Administration on
the 6th floor, Room# 6004 to complete the Occupational Workers Compensation Program (OWCP) forms.
6. If you are a UCSD Paid employee, you will need to notify your UCSD HR.
7. If you are a VMRF Paid employee, you will need to notify VMRF at x7606.
8. If your injury is to the extent where you are admitted to the Emergency Department (ED) here at the
VASDHS, please remember that you may be liable for the expenses that are not covered by your respective
medical insurance company. Many times the person may be admitted to the ED, but then will be transported
to the hospital of choice by your insurance company. It is up to your medical insurance provider to make that
decision so you need to contact them as soon as possible. If you are not able to do so, then you need to
have a family member or friend contact your insurance company for you.
9. If you have any questions please call Yolanda at x7014 or come and see her in room 6004.
Check All Boxes that Apply:
Veteran
UCSD-Paid
VA-Paid
VMRF-Paid
Person to contact in case of an emergency:
Printed First & Last Name
Street Address
Phone Number
City
State
Employee Signature
Date
I have read this statement.
Printed First & Last Name
VA San Diego Healthcare System
Occupational Health - Without Compensation (WOC) Clearance
BY APPOINTMENT ONLY - CALL EXTENSION 3214 FOR APPOINTMENT
Section I: TYPE OR PRINT LEGIBLY
1. Name: ________________________________________________ Male
Female
(last, first, middle initial)
2. Full Social Security: _____-_____-_______
3. Date of Birth (mm/dd/yy)__________
4. Service/Section: ________________/_____________
5. Contact phone: _________________
6. Email Address: ________________@_________________
7. Agency affiliation: VA
UCSD
VMRF
Student/Trainee
Section II: Must be completed and signed by the Principal Investigator (PI)/Service POC:
(Prior to Occupational Health Appointment)
1.
2.
3.
4.
5.
6.
7.
8.
Anticipated Date of appointment for this WOC: ___________________________________
Anticipated Length of appointment: _____________________________________________
WOC Position Title: ____________________________________
Service/Section: ___________________/__________________________
Work location (be specific): _____________________
Name of Service administrator or designated contact:______________________________
Phone # and Extension of Service contact: _____________________________________
Will this individual be in contact with human or primate blood, tissue samples or have direct
patient contact other than verbal interaction? Yes
No
IF “yes” please describe below:
________________________________________________________________________________
________________________________________________________________________________
9. Name of PI/Service POC: _________________________________________________
10. Signature of PI/Service POC: _______________________________ Date: _________
Section III: Occupational Health Use Only
1. Quantiferon: Date blood drawn____________
2. Tuberculosis surveillance: Baseline
3. Initial: History of +ppd: Yes
Annual
No
Renewal
Date of CXR:____________
4. If ppd negative date of reading: __________
5. Date next TB test due: ________________
Final Clearance Date: ________________OH Signature: __________________________________
FINGERPRINT REQUEST FORM
Research WOC
INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service: Room 1508, Monday –Friday,
7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.
Section I to be completed by the Employee
Name:
Date:
Other Names Used:
Position Title:
Social Security Number:
Service/Mail Code: RESEARCH
Phone:
Email:
Date of Birth:
City/State/Country of Birth:
Country of Citizenship:
Male
Anticipated Start Date (EOD):
Length of Appointment:
Applicant Category (check one): Paid
Resident Student
Contractor
Volunteer
Fee-Basis
Contract #:
MC (151)
Female
Work-Study
Research WOC: UCSD
/
IPA
VMRF
Extern
6 months
1 yr
2 yrs
Intern (non medical)
OTHER:
Contract Company:
Section II to be completed by Research POC or COTR
Service POC / COTR Sponsor: Robert Atienza
Send Fingerprint Results to: Robert Atienza
Phone: 858-552-8585 x1159
Mail Code: 151
Section III to be completed by Police Service
Date Completed:
Police Service Name:
Signature:
Section IIII to be completed by HUMAN RESOURCES
SAC Completed Date:
HR Name:
HR Signature:
**UPON COMPLETION OF THIS FORM POLICE SERVICE WILL ROUTE THIS FORM TO HUMAN RESOURCES**
FINGERPRINT VERIFICATION FORM
Research WOC
INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service with your Fingerprint Request form: Room
1508, Monday –Friday, 7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.
Section I to be completed by the Employee
Name:
Date:
Position Title:
Length of Appointment:
Social Security Number:
Service/Mail Code: RESEARCH
Phone:
Email:
Date of Birth:
City/State/Country of Birth:
Country of Citizenship:
Male
6 months
/
1 yr
2 yrs
MC (151)
Female
Section II to be completed by Research POC or COTR
Service POC / COTR Sponsor: Robert Atienza
Phone: 858-552-8585 x1159
Send Fingerprint Results to: Robert Atienza
Mail Code: 151
Section III to be completed by Police Service
Date Fingerprints Completed:
Police Service Name:
Signature:
**UPON COMPLETION OF THIS FORM RETURN TO RESEARCH ADMINISTRATION WITH YOUR WOC PACKET**
PIV Badge Request Form
Name: ___________________________
Date of Birth: __________________
Social Security Number: _____________
VA Computer Account: Y / N (va.gov only)
Place of Birth (city & state):_________________________
Research Job Title: ________________________________
E-Mail: _______________________________
Sex: M
Work Phone: _______________
F
Race: ________________
Height: _______________ (feet ‘inches)
Weight: _______________ (pounds)
Eyes: _________________
Hair: _________________
Research Admin Office Use Only
NACI Submitted: _____________
NACI Issues: ___________________________________________________
NACI Re-submitted: ___________
NACI Closed: ________________
PIV Badge Processed: __________
ANNUAL RECORD OF EMPLOYEE COMPETENCE
ORGANIZATIONAL
NAME:_________________________________________________________
POSITION: ____________________________________________________
SERVICE: __________________________________________________
SUPERVISOR: ____________________________________________
Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”
COMPETENCY &
OUTCOMES
BEHAVIORS
*
VALID
(Circle
validation
code)
Demonstrates Teamwork
Assists others to complete work.
DORST
Protects Patient Rights
DORST
Manages Resources
Protects patient confidentiality and
privacy, including verbal, written and
computer-generated information.
Manages work time.
Acts in a Responsible Manner
Meets timelines and completes tasks.
DORST
Promotes Customer
Satisfaction
Greets customers with a smile and eye
contact.
Responds to customer requests and follows
up as soon as possible.
Does not falsify data or records.
DORST
Maintains clean work area, promotes
facility cleanliness by wiping up own spills
and/or notifying Environmental
Management Service as soon as possible
for needed clean up.
Protects self and others by practicing
proper hand hygiene and cough etiquette.
Practices standard contact precautions.
Demonstrates knowledge and accurate use
of computer systems as applicable to job
position.
Maintains computer security by logging
off and protecting passwords.
DORST
Demonstrates Ethical Behavior
Environmental Management
Infection Control
Information Management
Updated April 16, 2013
DORST
DORST
DORST
DORST
DORST
DORST
INITIALS
DATE
Supervisor
Employee
COMMENTS
Participates in Performance
Improvement
Respects Diversity in Others
Problem Solving/Conflict
Resolution
Provides Specific Population
Appropriate Care
Supports and helps implement
improvements.
Demonstrates respect of cultural, ethnic,
religious, gender, sexual orientation and
disability differences in others during
interactions.
Offers solutions to problems and conflicts.
DORST
DORST
DORST
DORST
Veteran Specific: World War II; Korea;
Cold War; Vietnam War; Gulf War;
OEF/OIF/OND; PTSD; TBI; MST;
Women’s Health
DORST
Age Specific Care: Young Adult (18-40);
Middle Adult (40-65); Later Adult (65+)
DORST
Cultural Diversity and Belief/Spiritual
Considerations: American Indian;
Asian/Pacific Islander; Hispanic; African
American; Educationally Disadvantaged;
Mentally &/or Physically Disabled;
Beliefs; Spiritual Issues
Each item is to be dated and initialed individually. The use of ditto marks or continuation lines are not permitted.
* VALIDATION METHOD CODES: D Demonstration
O Observation
Circle the applicable validation code.
R Record Review
S Simulation
T Test (ONLY for safety competencies)
Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.
All of the competencies have been validated.
The employee requires further education to obtain the skills and techniques necessary to competently complete his/her job
duties. Employee will be given further instruction on
and re-evaluated in 90 days.
Supervisor/Designee Signature _________________________________________________________________ Date ______________________________
Employee Signature _____________________________________________________________________________ Date ______________________________
Updated April 16, 2013
ANNUAL RECORD OF EMPLOYEE COMPETENCE
SAFETY
NAME:_________________________________________________________
POSITION: ____________________________________________________
SERVICE: __________________________________________________
SUPERVISOR: _____________________________________________
Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”
INITIALS
*
COMPETENCY &
OUTCOMES
Safety risk in hospital environment
Reporting procedures for
incidents involving property
damage, occupational illness, and
injury to
patients, staff, or visitors
Activates use of hospital color
code system based on type of
emergency
Activates emergency protocol for
Community Based Outpatient
Clinics and other off-site VA
locations
Fall Prevention and Management
Plan
Actions to eliminate, minimize, or
report safety risks
Hospital-specific fire evacuation
routes
Specific roles and responsibilities
when at fire’s point of origin
Updated April 16, 2013
BEHAVIORS
VALID
(Circle
validation
code)
Notifies supervisor of hazardous
area.
Uses proper forms for reporting
incidents.
DORST
Calls Hospital Operator (x-3333)
to activate Code
Blue/Red/Yellow/Green/Purple/W
hite.
Calls 9-1-1.
DORST
Can describe the organization’s
Fall Prevention and Management
Plan and knows the color code
used to identify High Fall Risk
Patients (yellow).
Initiates work order to have
problem resolved.
Can describe evacuation routes
out of work area.
Can demonstrate the process
described by acronyms R.A.C.E.
and P.A.S.S.
DORST
DORST
DORST
DORST
DORST
DORST
DATE
Supervisor
Employee
COMMENTS
DORST
Specific roles and responsibilities
Is familiar with the alarm code.
when away from a fire’s point of
origin
DORST
Use and functioning of fire alarm
Knows when and how to activate
systems when required
fire alarm.
DORST
Use and functioning of fire alarm
Knows when and how to activate
systems when required.
fire alarm.
DORST
Specific roles and responsibilities
Can articulate roles and
in preparing for building
responsibilities during evacuation
evacuations
of staff and patients.
Each item is to be dated and initialed individually. The use of ditto marks or continuation lines are not permitted.
D Demonstration
*VALIDATION METHOD CODES:
Circle the applicable validation code.
O Observation R Record Review
S Simulation
T Test (ONLY for safety competencies)
Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.
All of the competencies have been validated.
The employee requires further education to obtain the skills and techniques necessary to competently complete his/her job
duties. Employee will be given further instruction on
and re-evaluated in 90 days.
Supervisor/Designee Signature _________________________________________________________________ Date ______________________________
Employee Signature _____________________________________________________________________________ Date ______________________________
Updated April 16, 2013
ANNUAL RECORD OF EMPLOYEE COMPETENCE
Job Specific
NAME: _________________________________________________________
POSITION: ____________________________________________________
SERVICE: __________________________________________________
SUPERVISOR: ____________________________________________
Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”
INITIALS
*
COMPETENCY &
OUTCOMES
BEHAVIORS
VALID
(Circle
validation
code)
DATE
Supervisor
COMMENTS
Employee
DORST
DORST
DORST
DORST
DORST
Each item is to be dated and initialed individually. The use of ditto marks or continuation lines are not permitted.
* VALIDATION METHOD CODES:
D Demonstration
O Observation
competencies)
R Record Review
S Simulation
T Test (ONLY for safety
Circle the applicable validation code.
Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.
All of the competencies have been validated. Note: Job Competencies are specific to the job the employee is assigned to.
The employee requires further education to obtain the skills and techniques necessary to competently complete his/her job
duties. Employee will be given further instruction on
and re-evaluated in 90 days.
Supervisor/Designee Signature _________________________________________________________________ Date ______________________________
Employee Signature _____________________________________________________________________________ Date ______________________________
Updated April 16, 2013
ANNUAL RECORD OF EMPLOYEE COMPETENCE
SUPERVISOR/MANAGER
NAME:_________________________________________________________
POSITION: ____________________________________________________
SERVICE: __________________________________________________
SUPERVISOR: ____________________________________________
Competencies are assessed over time. Documentation may be completed on one date. If competency does not apply to job position, write N/A under “Comments.”
INITIALS
*
COMPETENCY &
OUTCOMES
BEHAVIORS
VALID
(Circle
validation
code)
Plans/Organizes
Prioritizes work activities.
DORST
Leadership
Empowers staff to make decisions.
DORST
Manages Conflict
Facilitates constructive conflict
resolution.
DORST
Recognizes and rewards
competence
Manages Operations and
Resources
DATE
Supervisor
Employee
COMMENTS
DORST
Recognizes and rewards individuals and
teams for exceptional performance and
special contributions.
DORST
Uses performance measures to monitor
operations.
Each item is to be dated and initialed individually. The use of ditto marks or continuation lines are not permitted.
S Simulation T Test (ONLY for safety competencies)
* VALIDATION METHOD CODES: D Demonstration O Observation R Record Review
Circle the applicable validation code.
Anything less than competent requires a plan to re-educate/train employee and documentation of re-evaluation of competency.
All of the competencies have been validated.
The employee requires further education to obtain the skills and techniques necessary to competently complete his/her job
duties. Employee will be given further instruction on
and re-evaluated in 90 days.
Supervisor/Designee Signature _________________________________________________________________ Date ______________________________
Employee Signature _____________________________________________________________________________ Date ______________________________
Updated April 16, 2013