ALAMEDA COUNTY
HEALTH CARE SERVICES AGENCY
HUMAN RESOURCES DEPARTMENT
(CONFIDENTIAL)
EMPLOYEE FACE SHEET
PLEASE PRINT LEGIBLY - Complete all requested information
GENERAL INFORMATION
LAST NAME:
FIRST NAME: (as shown on social security card)
HOME ADDRESS:
CITY, STATE, ZIP CODE:
EMPLOYEE ID:
APT. or UNIT #:
COUNTY:
HOME PHONE NUMBER:
MAILING ADDRESS IF DIFFERENT:
CELL PHONE NUMBER:
LIST OTHER NAMES UNDER WHICH YOU HAVE BEEN EMPLOYED:
E-MAIL ADDRESS:
PERSONNEL INFORMATION
DEPARTMENT NAME and WORK ADDRESS:
UNIT and/or FLOOR NUMBER:
CITY, STATE, ZIP CODE:
WORK PHONE NUMBER:
QIC CODE:
SUPERVISOR’S NAME:
EMERGENCY INFORMATION
PRIMARY CONTACT TO BE NOTIFIED IN CASE OF EMERGENCY:
RELATIONSHIP:
ADDRESS:
TELEPHONE NUMBER:
CITY, STATE AND ZIP CODE:
ALTERNATE TELEPHONE NUMBER:
SECONDARY CONTACT TO BE NOTIFIED IN CASE OF EMERGENCY:
RELATIONSHIP:
ADDRESS:
TELEPHONE NUMBER:
CITY, STATE AND ZIP CODE:
ALTERNATE TELEPHONE NUMBER:
_____________________________________
Employee’s Signature
______________________________
Date
Return documents to QIC 42601 Human Resources Dept., HCSA or Fax # 866-521-3819
(Revised 6/1/17)
STATE OF CALIFORNIA
COUNTY OF ALAMEDA
)
) ss.
)
_____________________________________
Print or type your name on this line
OATH OR AFFIRMATION OF ALLEGIANCE
I, _________________________________________, do solemnly swear (or affirm) that I will
support and defend the Constitution of the United States and the Constitution of the State
of California against all enemies, foreign and domestic; that I will bear true faith and
allegiance to the Constitution of the United States and the Constitution of the State of
California; that I take this obligation freely, without any mental reservation or purpose of
evasion; and that I will well and faithfully discharge the duties upon which I am about to
enter.
_________________________________________
Signature
Subscribed and sworn to before me
________________________, 20____
_______________________________
_______________________________
COUNTY OF ALAMEDA
HRMS Time and Labor
PROGRAM
Self Service Time Entry and Approval Participation Agreement
(Employee and Agency/Department)
Updated 11/28/11
This agreement is entered into on_________________by and between __________________
hereinafter referred to as “EMPLOYEE” and ____________________ hereinafter referred to as
“AGENCY/DEPARTMENT”.
EMPLOYEE is desirous of participating in the Self Service Time Entry Program. PROGRAM
referred to hereinafter is the Self Service Time Entry and Approval Program.
AGENCY/DEPARTMENT is desirous of approving the participation of the EMPLOYEE in the
PROGRAM.
EMPLOYEE Agrees to the following statements:
1.
I understand that I must have a LOGON ID and Password to participate in the PROGRAM.
I agree not to share my LOGON ID and Password with anyone. The LOGON ID and
Password identifies EMPLOYEE in the HRMS Time and Labor system
2.
I understand participation in the PROGRAM is contingent on a fully executed Self Service
Participation Agreement from myself as well as my Supervisor and is to remain on file
with the AGENCY/DEPARTMENT.
3.
I will be responsible for inputting my own work and/or leave time by accessing the HRMS
Time and Labor time entry system.
4.
I understand that my input to the HRMS Time and Labor time entry “Timesheet” may
begin the Monday after payday and must be completed before 7:00 PM on the Saturday
following payday (two-week period).
5.
I understand that if I miss the timeframe stated in #4 (i. e., by virtue of being on paid or
unpaid leave or for any reason during the timeframe), I will need to complete a timesheet,
or the document in use by my department to support time entry, and forward to my
supervisor for approval.
6.
I understand that the HRMS Time and Labor time entry system will give me an error
message if I try to use leave time (sick leave, vacation, floating holiday, comp time, etc.)
that I do not have. In the event I receive an error message because I do not have sufficient
leave, I also understand that I need to consult with my supervisor prior to changing the
leave I have entered. If I do not have sufficient leave and/or my supervisor does not
approve the use of said leave, I will enter leave without pay (LWO) for the number of
hours for which I have no leave.
7.
I understand by participating in this PROGRAM I still need to seek advance approvals of
leave time and overtime.
8.
I understand that in order for the EMPLOYEE to participate in the PROGRAM my
MANAGER/SUPERVISOR must participate in the PROGRAM and vice versa.
9.
I acknowledge receiving information about Alameda County’s Self Service Time Entry
Program.
10.
I understand the AGENCY/DEPARTMENT may terminate this agreement at any time the
PROGRAM does not prove to be in the best interest of the AGENCY/DEPARTMENT.
11.
The Auditor-Controller reserves the right to deny or terminate participation in the
PROGRAM at any time either party fails to comply with the terms and conditions of this
agreement.
12.
The Auditor-Controller reserves the right to deny participation in the PROGRAM and/or
terminate the PROGRAM at any time the PROGRAM does not prove to be in the best
interest of the AGENCY/DEPARTMENT and/or County.
AGENCY/DEPARTMENT Agrees to the following statements:
1. The Department Security Administrator will submit Security Request Form to ITD
Security for EMPLOYEE and SUPERVISOR at any time either party agrees to terminate
participation in the PROGRAM.
2. Understand the time entry information entered in the HRMS Time and Labor time entry
system by the EMPLOYEE and approved by the SUPERVISOR will be accessible for
review at a later date and readily available for audit by the County, Grand Jury Auditors,
grantee funding sources and other regulatory authorities.
3. At any time, the EMPLOYEE and/or MANAGER/SUPERVISOR do not complete the
time entry process during the prescribed timeline, the responsible person in the
AGENCY/DEPARTMENT will provide the Department Timekeeper/Payroll Clerk with
the authorized time entry for the EMPLOYEE to enter to the HRMS Time and Labor
system for the next available pay day.
4. Understands that an EMPLOYEE and MANAGER/SUPERVISOR may not enter and
approve their own time in the HRMS Time and Labor time entry system.
5. The Auditor-Controller reserves the right to deny or terminate participation in the
PROGRAM at any time either party fails to comply with the terms and conditions of this
agreement.
6. The Auditor-Controller reserves the right to deny participation in the PROGRAM and/or
terminate the PROGRAM at any time the PROGRAM does not prove to be in the best
interest of the AGENCY/DEPARTMENT and/or County.
It is mutually agreed to as follows:
This agreement can be modified when either party decides to discontinue participation in the
PROGRAM by providing in advance 14 days notice.
At any time, the EMPLOYEE leaves County service, transfers to another
AGENCY/DEPARTMENT or the relationship of EMPLOYEE and AGENCY/DEPARTMENT
changes, this agreement becomes null and void.
All parties have read, understand and agree to the contents of this agreement
_______________________
EMPLOYEE (Print Name)
__________________________________________
AGENCY/DEPART HEAD/DESIGNEE (Print Name)
_______________________
EMPLOYEE (Signature)
______________________
EMPLOYEE ID
____________________
Date Signed
__________________________________________
AGENCY/DEPT HEAD/DESIGNEE (Signature)
_________________________
EMPLOYEE ID
_________________________
Date Signed
NOTE: Return the fully executed agreement to your Departmental Representative.
COUNTY OF ALAMEDA
PRE-DESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such
injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:
• Your employer offers group health coverage;
• The doctor is your regular physician, who shall be either a physician who has limited his or her
practice of medicine to general practice or who is a board-certified or board-eligible internist,
pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your
medical treatment, and retains your medical records;
• Your “personal physician” may be a medical group if it is a single corporation or partnership
composed of licensed doctors of medicine or osteopathy, which operates an integrated
multispecialty medical group providing comprehensive medical services predominately for nonoccupational illness and injuries;
• Prior to the injury your doctor agrees to treat you for work injuries or illnesses; and
• Prior to the injury you provided your employer the following in writing: (1) notice that you want
your personal doctor to treat you for a work-related injury or illness, and (2) your personal
doctor’s name and business address.
You may use this form to notify the County if you wish to have your personal medical doctor or a doctor
of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.
Employee’s Name (Print): _____________________________________________________________
Employee’s Address:__________________________________________________________________
Signature_________________________________________________________Date:______________
If I have a work-related injury or illness, I choose to be treated by:
___________________________________________________________________________________
Name of doctor
___________________________________________________________________________________
Street Address, City, State, ZIP
Telephone number
Check here if you do not wish to pre-designate at this time
Physician: Complete this section.
I agree to this pre-designation. __________________________________________________________
(Physician or Designated Employee of the Physician)
Date
The physician is not required to sign this form; however, if the physician or designated employee of the
physician does not sign, other documentation of the physician’s agreement to be pre-designated will be
required pursuant to Title 8, California Code of Regulations, §9780.1(a)(3).
EMPLOYEE: This form must be returned to your department’s personnel office or personnel officer.
DEPARTMENT: Place this in the employee file. If a workers’ compensation claim is filed, please send
a copy of this form along with the DWC-1, 5020, and Supervisor’s Report of Injury to the third party
administrator.
(Modified DWC FORM 9783; Revised 11/2010)
COUNTY OF ALAMEDA
Pre-Designation of Personal Physician
Frequently Asked Questions
What does pre-designation mean?
State law gives you the right to be treated by your personal physician for an industrial injury, from the
date of injury, if you have notified your employer in writing prior to the date of the injury.
What happens if I do not pre-designate?
Medical treatment will be provided by a physician that you select from the list of County
approved/designated physicians. If you receive medical treatment for an industrial injury within the first
thirty (30) days of reporting the injury from a physician who, 1) is not your pre-designated physician or,
2) is not a County-approved/designated physician, the treatment may be considered unauthorized and you
will be responsible for the costs incurred.
Who may I pre-designate as my personal physician?
Per Labor Code, a "personal physician" must:
• Be a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.);
• Be your regular physician, who shall be either a physician who has limited his or her practice of
medicine to general practice or who is a board-certified or board-eligible internist, pediatrician,
obstetrician-gynecologist, or family practitioner, and has previously directed your medical
treatment, and retains your medical records. This includes a medical group if it is a single
corporation or partnership composed of licensed doctors of medicine or osteopathy, which
operates ad integrated multispecialty medical group providing comprehensive medical services
predominantly for non-occupational illness and injuries;
• Prior to the injury, agree to treat you for work related injuries or illnesses consistent with Stateapproved or ACOEM guidelines;
• Bill the medical service in accordance with the California Official Medical Fee Schedule
• Complete the Pre-Designation of Personal Physician form prior to the injury;
Who will treat me if my industrial injury is a medical emergency?
As your employer, the County is obligated to see that you get immediate medical treatment in an
emergency from the closest available source. You have the right to be treated by your pre-designated
personal physician after emergency care is no longer medically required.
Suppose I change personal physicians sometime in the future due to a change of health plans, how do
I up-date my pre-designation information?
If you need to change the name of the physician or medical service that you pre-designated, simply fill out
another pre-designation form and send it to your department/agency personnel administrator. Be sure you
sign and date the new form.
Once I am under a physician's care for an industrial injury, can I change treating physicians?
Yes, state law entitles you to request and be granted a change of treating physicians. You can exercise this
option at any point thirty (30) days after reporting the injury to the County. You must advise the County's
Workers' Compensation Third Party Administrator in advance of making the change.
NOTE: Referral by your primary treating physician to a specialist (e.g., orthopedist, neurologist) is not
considered a change of treating physician.
If you have any questions, please contact your department Workers’ Compensation liaison, personnel
officer or the County Workers’ Compensation Administrator at (510) 272-6045, tie line 26045.
(Revised 11/2010)
LABOR CODE SECTION 4600(d)
(1) If an employee has notified his or her employer in writing prior to the date of injury that he or she has
a personal physician, the employee shall have the right to be treated by that physician from the date of
injury if either of the following conditions exist:
(A) The employer provides non-occupational group health coverage in a health care service plan,
licensed pursuant to Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and
Safety Code.
(B) The employer provides non-occupational health coverage in a group health plan or a group health
insurance policy as described in Section 4616.7.
(2) For purposes of paragraph (1), a personal physician shall meet all of the following conditions:
(A) Be the employee's regular physician and surgeon, licensed pursuant to Chapter 5 (commencing with
Section 2000) of Division 2 of the Business and Professions Code.
(B) Be the employee's primary care physician and has previously directed the medical treatment of the
employee, and who retains the employee's medical records, including his or her medical history.
“Personal physician” includes a medical group, if the medical group is a single corporation or
partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated
multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries.
(C) The physician agrees to be pre-designated.
(3) If the employer provides non-occupational health care pursuant to Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code, and the employer is notified pursuant to
paragraph (1), all medical treatment, utilization review of medical treatment, access to medical
treatment, and other medical treatment issues shall be governed by Chapter 2.2 (commencing with
Section 1340) of Division 2 of the Health and Safety Code. Disputes regarding the provision of
medical treatment shall be resolved pursuant to Article 5.55 (commencing with Section 1374.30) of
Chapter 2.2 of Division 2 of the Health and Safety Code.
(4) If the employer provides non-occupational health care, as described in Section 4616.7, all medical
treatment, utilization review of medical treatment, access to medical treatment, and other medical
treatment issues shall be governed by the applicable provisions of the Insurance Code.
(5) The insurer may require prior authorization of any non-emergency treatment or diagnostic service and
may conduct reasonably necessary utilization review pursuant to Section 4610.
(6) An employee shall be entitled to all medically appropriate referrals by the personal physician to other
physicians or medical providers within the non-occupational health care plan. An employee shall be
entitled to treatment by physicians or other medical providers outside of the non-occupational health
care plan pursuant to standards established in Article 5 (commencing with Section 1367) of Chapter
2.2 of Division 2 of the Health and Safety Code.
(Revised 9/2010)
COUNTY OF ALAMEDA
APPROPRIATE USE OF TELECOMMUNICATIONS AND
INFORMATION TECHNOLOGY SYSTEMS POLICY
INTRODUCTION
In recent years Alameda County has made a significant investment in information technology
(IT) systems, in order to make employees more efficient in their jobs. Because of advances in
this technology, there is now more responsibility placed on the employee to ensure that
computers, software, data, and all telecommunication devices used on behalf of the County are
used appropriately and for appropriate County purposes. Adequate safeguards must be in place
for both the employees’ and the County's protection. This document is intended to inform
employees of County policy in this area. To the extent that this policy may not cover every
possible situation, common sense should be exercised at all times regarding appropriate work
place use of IT systems by employees in public service. Nothing contained in this policy shall
prevent employees from using the necessary software, social media outlets, or other IT resources
in order to complete their assigned duties as explained more fully below. If you are unsure
regarding the appropriateness of what you want to do, ask your department head or designee.
As used in this policy, the phrases “IT systems” and “IT resources” include all computers,
telephones (including cellular phones), personal digital assistants (PDAs), radio hardware
(including peripherals), software applications and data (including email and voice mail), social
media, networks and network connections (including the Internet), and documentation and other
capabilities intended for the purpose of processing, transferring, or storing data in support of
County goals. The term “user” includes permanent, provisional, temporary, and project
employees, as well as persons hired by the County on a contract basis.
As used in this policy, forms of “social media” include but are not limited to discussion forums,
chat rooms, blogs, podcasts, Wikis, RSS feeds, photo and video sharing, and any type of social
networks.
EMPLOYEE RESPONSIBILITIES
• Protect your user ID and password.
Your user IDs and passwords should not be shared with anyone unless there is a legitimate
business reason. Change your password frequently and do not write it down. If a password is
compromised for any reason, the password shall be changed as soon as possible.
• Access to IT systems, data, and networks.
You may access data for which you have been authorized in the normal performance of your job
duties. You must respect the privacy of clients and co-workers by not sharing information unless
required for business purposes.
• IT systems are to be used only for authorized Alameda County business.
County-owned or leased equipment is to be used for business purposes only. If you are unsure of
what is appropriate in your department, ask your department head, designee, or departmental
human resources personnel.
Activities prohibited by this policy include, but are not limited to, the following:
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Transmittal or use of any material in violation of any federal, state, or local law,
ordinance, or regulation;
Transmittal or use of any material or communication that is threatening, defamatory,
obscene, discriminatory, or offensive;
Accessing inappropriate websites;
Transmitting personal opinions or personal data via County telecommunication devices;
Use of any County IT system for commercial or financial gain;
Personal use including, but not limited to, financial transactions, shopping, stock trading,
etc.;
Misrepresentation under any circumstances of a user’s true identity;
Unauthorized access to any County IT system;
Any action intended to accomplish or assist in unauthorized access to County IT systems;
Unauthorized or improper downloading, accessing, or transmittal of copyrighted
information, documents, or software;
Disclosure of any confidential information that could breach the security of any County
IT system;
Transmittal of unauthorized broadcast communications or solicitations (such as mass
email transmissions);
Any action that causes the County to incur a fee for which there has not been prior
approval;
Use of a security code or password other than as authorized;
Deliberately attempting to disrupt any County IT system or network performance, or to
destroy data by spreading or introducing computer viruses or other malware;
Establishing or modifying web sites for any purpose unless such activity is part of the
employee’s normal job functions or is directed by the Agency Director or Director’s
designee.
2
• IT resources
Use only legally acquired and licensed software.
All County IT resources shall remain the property of the County of Alameda and may be
examined at any time. Users must not install, upgrade, repair, or remove IT resources without IT
management approval. Proprietary or County-developed software must not be copied or
distributed without management approval.
There is a significant financial liability to the County if software that has not been legally
obtained is used on County-owned equipment.
Only software that has been legally acquired and licensed may be used. Check the
documentation provided with the software before you make copies for others. Generally you
may make copies of software for back-up purposes only.
There is a potential for introducing a virus into a County-owned system, and possibly even
Countywide, whenever outside software is used. If you need to use an outside software program
for business purposes, you must first obtain permission from your department head or designee.
If you need to download County forms or documents in the course of your job duties to an
external portable device such as a flash drive, you must receive authorization from your
department head or designee. The County shall provide such devices, subject to the following
conditions:
 Employees must use County-provided external portable devices only for those purposes
authorized by the County;
 Employees must safeguard the devices and immediately report any loss;
 Employees shall have no expectation of privacy in any materials downloaded to the
devices
Only County-approved equipment is to have a permanent physical connection to County
networks. Users should consult with their System Administrator for the proper use of portable
devices and the relocation and reconnection of desktop devices.
The County cannot provide technical support of unapproved IT resources. Installation, upgrade,
repair, or other forms of support will only be performed on official County-owned, leased, or
licensed IT resources. Employee-owned equipment shall not be supported by the County.
• Social media
Strategic use of social media may help the County foster positive relationships with key
audiences such as clients/consumers, community based partners, taxpayers, voters, government
peers, employees, and other stakeholders. Use of social media in the course and scope of the
performance of an employee’s job duties shall occur only after permission for such use has been
obtained from the department head or designee, and only to the extent authorized.
Personal use of any type of social media during on-duty working hours is prohibited. Using
County IT systems or IT resources to access non-County business social media sites is prohibited
for non-County related activities.
3
Employees must adhere to federal, state, County and department/agency compliance rules and
policies when using or participating in social media. This includes protecting confidentiality,
privacy, and security, and safeguarding Alameda County and department/agency assets and
public image.
Employees shall abide by copyright laws by ensuring that they have permission to use or
reproduce any copyrighted text, photos, graphics, videos, or other materials owned by other
individuals or groups.
Employees shall not post any material that is obscene, defamatory, profane, libelous, threatening,
harassing, or abusive.
• Workplace privacy
Users of County IT systems shall have no expectation of privacy with regard to the use of
such systems. Alameda County retains the right to examine all electronic storage media, data
files, logs, and programs that are part of any County IT system. Moreover, users shall have no
expectation of privacy with regard to any work-related materials created on non-County IT
systems, upon emailing or transmitting such work-related materials to any recipient.
System administrators are authorized to examine, remove from distribution, and/or retain
electronic files within the scope of their responsibilities to troubleshoot and/or repair the IT
resources under their purview. Content in violation of policies or the law will be reported to
management and appropriate action shall be taken.
This Appropriate Use Policy is intended as a starting point and may be enhanced by your
department to cover any special circumstances. County agencies and departments are prohibited
from adopting rules that conflict with this County-wide policy.
• Violations of this policy
Violations of this policy will be handled in a manner consistent with the County’s disciplinary
process up to and including termination, and may be subject to prosecution by local, state, and
federal authorities.
I acknowledge that I have received and have been given the opportunity to read this document.
____________________________
Print Name
_______________________
Date
__________________________
Signature
ALAMEDA COUNTY REFERENCES:
Board of Supervisors File No. 28545, Item No. 38
APPROVED FOR DISTRIBUTION:
BOS Approved: November 6, 2012
4
ALAMEDA COUNTY
2021
USE LESS PAPER: PRINTING TWO SIDES SAVES
PRINTED ON 100% RECYCLED PAPER WITH SOY-BASED INK
FEBRUARY
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Friday, January 1
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OFFICIAL COUNTY HOLIDAYS
MEMORIAL DAY
Observed, Monday, May 31
THANKSGIVING
Observed Thursday/Friday, November 25 & 26
MARTIN LUTHER KING JR.’S BIRTHDAY
Observed, Monday, January 18
INDEPENDENCE DAY
Observed, Monday, July 5
CHRISTMAS
Observed Friday, December 24
LINCOLN’S BIRTHDAY
Friday, February 12
LABOR DAY
Observed, Monday, September 6
WASHINGTON’S BIRTHDAY
Observed, Monday, February 15
VETERANS DAY
Thursday, November 11
Bold = Holidays
= Pay Days
HEALTH CARE SERVICES AGENCY BI-WEEKLY TIME RECORD
EMPLOYEE NAME (PRINT):
EMPLOYEE ID NUMBER:
FROM
PAY PERIOD:
TO
HRMS DEPT/LOC:
SHOW ALL TIME IN HOURS AND TENTHS ONLY (SEE MINUTES TABLE ON REVERSE SIDE).
Sun
TRC
Mon
Tues
Wed Thurs
Fri
Sat
SHIFT
TOTAL
HOURS
ORG#/PROJECT/
PROGRAM NUMBER
TOTAL
HOURS
ORG#/PROJECT/
PROGRAM NUMBER
TOTAL
HOURS
1ST WEEK TOTAL
Sun
TRC
SHIFT
Mon
Tues
Wed Thurs
Fri
Sat
TOTAL
HOURS
2ND WEEK TOTAL
PAY PERIOD
TOTALS
TO THE BEST OF MY KNOWLEDGE, I CERTIFY THAT I HAVE CORRECTLY REPORTED ALL TIME FOR THIS PAY PERIOD ON THIS TIMESHEET.
EMPLOYEE SIGNATURE:
DATE:
REVIEWED AND APPROVED:
DATE:
NOTE: See reverse side for Instructions and Additional Time Reporting Codes (TRC).
ALAMEDA COUNTY HEALTH CARE SERVICES
ADULT/CHILD ABUSE AND DOMESTIC VIOLENCE REPORTING REQUIREMENTS
Sections 11160-11166 and 15632 of the California Health and Welfare Code and Alameda County Health Care
Services Agency policy require that all employees of the Agency be provided with a copy of this statement, and
that this statement be signed by such employees. It will be retained in the employees personnel file or in another
appropriate file.
The Health and Welfare Code provides as follows:
For Child Abuse
Any employee who has knowledge of or observes a child in his/her professional capacity or within the
scope of his/her employment who he/she knows or reasonably suspects has been the victim of child abuse
shall report the known or suspected instance of child abuse to a child protective agency immediately or as
soon as practically possible by telephone and prepare and send a written report thereof within 36 hours of
receiving the information concerning the incident.
For Dependent Adult Abuse
Any employee who in his/her professional capacity or within the scope of his/her employment, either has
observed an incident that reasonably appears to be physical abuse, has observed a physical injury where the
nature of the injury, the location on the body or the repetition of the injury, clearly indicates that physical
abuse has occurred, or is told by an elder or dependent adult that he/she has experienced behavior
constituting physical abuse, shall report the known or suspected instance of physical abuse either to the longterm care ombudsman coordinator or to a local law enforcement agency when the physical abuse is alleged
to have occurred in a long-term care facility or to either the County Adult Protective Services Agency or to a
local law enforcement agency when the physical abuse is alleged to have occurred anywhere else,
immediately or as soon as possible by telephone and shall prepare and send a written report thereof within 36
hours.
For Domestic Violence
Any employee who in his/her professional capacity or within the scope of his/her employment, who has
knowledge of or has observed domestic violence or injuries caused by a deadly weapon, or whom he/she
knows or reasonably suspects has been the victim of domestic violence, shall report the known or suspected
instance of domestic violence to the appropriate police/sheriff’s department and to Adult Protective Services
immediately or as soon as practically possible by telephone and to prepare and send a written report thereof
within 36 hours of receiving the information concerning the incident.
Your supervisor and Medical Center Administration should be notified whenever you believe that you may be
required to report child or dependent adult abuse or domestic violence. In addition, often several hospital
employees and medical staff members will learn about the same instance of abuse or domestic violence. The
patient’s attending physician shall be responsible for making reports or identifying the member of the health care
team who shall assume this responsibility.
If you have any questions regarding this material or your reporting obligations, ask your supervisor or
contact Personnel Department.
I certify that I have read and understood this statement and will comply with my obligations under the Child and
Dependent Adult Abuse and Domestic Violence Reporting Laws.
___________________________________
Name (please print)
____________________________________
Employee’s Classification
___________________________________
Signature
____________________________________
Date
WORKPLACE VIOLENCE PREVENTION POLICY
Across the nation incidents of workplace violence and threats of violence have significantly increased in recent
years. Immediate victims as well as others are affected by incidents of workplace violence or threats of
violence, including fellow employees, family members and clients. The physical injuries, emotional distress
and potential loss of life resulting from incidents of workplace violence may have long-term effects. Incidents
of violence or threats of violence may also have an impact on productivity and the effectiveness of the
organization for an extensive period of time.
CAL OSHA defines workplace violence in three main categories:
•
Type I - An incident where the assailant has no legitimate relationship to the workplace and
usually enters the workplace to commit a robbery or other criminal act.
•
Type II - An incident involving a violent act by a recipient of a service provided by an
employee.
•
Type III - An incident committed by someone seeking revenge for perceived unfair treatment
by a co-worker, a supervisor, a manager, or an incident involving a domestic dispute where an
employee is threatened at work by someone with whom the employee has a personal
relationship.
Alameda County recognizes the importance of providing a safe work environment. In order to maintain a safe
work environment, Alameda County prohibits all types of violent behavior as well as unauthorized
possession of weapons at any County work site. Conduct which is prohibited includes, but is not limited to
violence, threats of violence, intimidation, physical fighting, or unauthorized possession of weapons by
employees. Such conduct will not be tolerated and will be grounds for immediate removal from the work site
and prompt termination of employment.
It is critical that any incident of violence or threat of violence is reported and not ignored. County
employees can decrease the odds of workplace violence occurrences if such incidents are not ignored.
Because of these safety considerations, when in the workplace or while on County business, employees
shall immediately report the following to their immediate supervisor or to the appropriate manager or
leave a message on the Alameda County Workplace Violence Prevention Telephone Hot Line, 208-1018 or
21018 on the tie-line:
1)
any person, including an employee, visitor, contractor, vendor, client, patient, etc., who
threatens, attempts, or commits an act of violence in the workplace; or
2)
any unauthorized use, possession, transferring or selling of a weapon.
The County will make every reasonable effort to maintain the confidentiality of individual(s) reporting
incidents of Workplace Violence. No guarantees can be made in all situations as the identity of the reporter
may be critical to the investigation and/or incident.
I ACKNOWLEDGE THAT I HAVE RECEIVED, READ AND UNDERSTAND THIS DOCUMENT
ON PREVENTION OF WORKPLACE VIOLENCE
Print Name:
Signature:
Classification: (must be entered if S.S.# is left blank)
Social Security Number:(optional)
Date:
Alameda County's Workplace Violence Prevention Policy is in conformance with California OSHA guidelines on safety and prevention
of workplace violence.
7/28/95;Rev. 12/29/95;Rev. 9/4/96; 5/24/01
ETHICAL CONDUCT
POLICY STATEMENT:
In accordance with Alameda County Behavioral Health Care Services (ACBHCS) standards, ethical conduct should be
evidence throughout the activities of all personnel of the organization including both management and direct service staff*,
County operated providers and the contractual providers which incorporates the Behavioral Health Plan’s provider network.
The ethical conduct should be seen in communications with the consumers served, payers, and the community. It is
expected that ethical conduct is shown in how clinicians involve the clients and their families in the treatment process and
outcomes, and how all persons that are part of or representative of the ACBHCS’ organization communicate with funding
sources and other regulatory agencies.
POLICY:
Alameda County Behavioral Health Care Services adheres to written codes of ethical conduct related to its organizational
staff, provider network, governance authority, business and financial practices, marketing activities, treatment of consumers
and community members.
ACBHCS has defined ethical codes and conduct for its organization by addressing primary philosophical beliefs, principles
and values that are considered exceptional in promoting the kind of relationships and subsequent environment whereby
services can be provided in an exceptional manner. Ethical conduct is expected at all levels of the organization, not only in
provisions of services and the correctness in billing for those services, but in everyday activities from the regular business
plans, decision-making processes, meetings and policy development.
ACBHCS’ ethical conduct policy is in accordance with the several licensing boards and professional organizations that
address their practitioners’ unprofessional conduct.
Besides the written Ethical Conduct policy and ethical conduct standards within contracts, orientation and educational
programs are provided to employees and contractual providers.
New employees of ACBHCS’ county-operated and contracted services are required to review and sign an ethical code of
conduct, indicating knowledge of this code and a non-disclosure agreement to protect confidentiality of medical and
behavioral health information.
ACBHCS resolves allegations of violations of its codes of ethical conduct by referring to the Credentials Committee when it
involves the BHP’s provider network and to the appropriate administrative operations office for county-operated and
contracted services.
CORE VALUES:
Following are the core values that act as a guidance tool for actions of staff and providers, treatment of consumers served,
business/financial practices and marketing
1. RESPECT FOR EACH OTHER
Thoughtful consideration of others including clients and their family members, colleagues, supervisors, staffs we
supervise, community members, other agency staffs, regulatory agencies and governing boards.
2. PROFESSIONAL PRACTICES
A commitment to professional practice that is competent, objective, and with integrity.
*All reference to staff will refer to both management, direct services and contracted staff.
3. HONESTY
The value of honesty cannot be compromised. It is expected that employees and contractors in their association
with consumers, agencies and other staffs will be honest without being harmful.
4. TRUST
A non-judgmental position on issues that do not directly pertain to you or your ability to conduct business provides a
supportive environment. When indicated during a time of need a supportive position for others is taken.
5. NON-DISCRIMINATORY MANNER
A commitment to society which offers opportunity to all its members in a just and non-discriminatory manner.
6. CLIENT PRIVACY
A commitment and obligation to monitor the privacy of both current and former clients, whether living or deceased,
and to monitor the confidentiality of material that has been transmitted to you in your professional role.
I. POLICY ON MEDI-CAL AND MEDICARE COMPLIANCE
COMPLIANCE CODE OF CONDUCT
Staff/contractor will adhere to Medi-Cal and Medicare standards and procedures as required by federal and state
regulatory agencies.
Staff/contractor will not knowingly and willingly falsify medical records by erroneously documenting assessment
findings, diagnostic formulations, or the amount of time and/or type of services rendered to consumers. Improper
alterations to documentation is included as medical records falsifications.
Staff/contractor is responsible to ensure the integrity and confidentiality of client and medical records information,
compliance from employees they supervise, and investigate and report any hazards or threats to the security or
integrity of client information to appropriate staff within your organization.
II. POLICY ON PROFESSIONAL RELATIONSHIPS
STANDARD
Staff/contractors do not exploit professional relationships sexually, financially or for any other professional and/or
personal advantage. This standard of conduct is maintained toward all who may be professionally associated with
you.
SEXUAL RELATIONSHIPS
Sexual activity or involvement with the staff member’s/contractor’s current or former ACBHCS service system client
is prohibited.
Sexual harassment of any ACBHCS client is prohibited. This includes sexual solicitation, physical advances, or
verbal or nonverbal conduct that is sexual in nature.
PERSONAL RELATIONSHIPS
Staff may provide to, receive from, or exchange articles of value with their clients only within the provisions of an
ACBHCS or contract agency-sanctioned program (e.g. art show and sale, food or clothing collection project, etc.)
When clients receive money or articles of value through an agency-sanctioned project, the client will not be informed
of the individual donor’s identity.
STAFF/CONTRACTOR ARE PROHIBITED FROM THE FOLLOWING:
Promising or entering into any personal, professional, financial or other relationship with a client that is not a part of
their assigned duties within the program at which they are employed.
Employing or using the services of their own current or former client for personal gain, except within the bounds of
an agency-sanctioned project.
Borrowing or accepting money or articles of value from clients, except within the bounds of an agency-sanctioned
project, e.g. approved culturally sensitive activity.
Loaning or giving personal funds or articles of value to clients, except within the bounds of an agency-sanctioned
project, e.g. provision of funds for clients when reimbursement of these funds by the agency will occur or approved
culturally sensitive activity.
Using the relative position of power afforded by their staff position to influence clients in any way not directly
relevant to the client’s treatment or service goals.
Living with their current or former ACBHCS clients.
Staff should refrain from religious proselytizing to clients and/or employees.
Providing massage to clients, except within the bounds of a formal job description and any applicable State
licensure.
Providing any form of treatment not sanctioned by the employing program’s formally recognized program design or
the service definitions and procedures of the ACBHCS.
III. POLICY ON SELF-PROMOTION AND REFERRAL
STANDARD
Clear, appropriate professional standards are set to prevent engagement in dual or multiple relationships in which
there is any risk of professional judgment being compromised, or of the client being harassed or exploited.
Staff may not refer ACBHCS clients to their own private practices, businesses, or any other service in which a staff
member has a personal or financial interest.
Staff will present themselves accurately and not misrepresent their roles, scope of practice or professional status in
the course of their work with clients and the community.
Staff may not receive self-referred ACBHCS client or ACBHCS clients referred by a third party into their private
practices except as follows:
Under certain exceptional circumstances, a client who initiates a request for a private professional
relationship with an ACBHCS service system staff member may be permitted to enter into such a
relationship if no other adequate public or private resource is available to meet the client’s needs.
Supervisory approval is required. Such approvals must be documented and the total number of such private
self-referrals must be reported by the Center/Executive Director at the end of each calendar year to the
Quality Assurance Administrator.
Under certain circumstances in order to meet client’s needs, ACCESS may refer to a private practitioner who
may also be employed by ACBHCS. This is done with the approval of the Director of ACCESS.
In order to protect the client from undue influence and the Agency from potential conflicts of interest, the staff
member receiving the private referral must attest to the guidelines listed on the Self-Disclosure Referral Form (see
attached).
Staff who have continuing private professional relationships with ACBHCS clients that were entered into either
before the effective date of this policy or that were entered into before the client became an ACBHCS client must
complete the Self-Referral Disclosure Form (see attached).
IV. SELF DISCLOSURE OR PRE-EXISTING PROFESSIONAL RELATIONSHIPS
It is the policy of this agency to comply with the Alameda County Behavioral Health Care Services “Policy on Multiple
Relationships and Staff Self-Promotion.” In recognition of the rights of clients to exercise choice in therapeutic relationships
under appropriate circumstances, the following disclosure information will be filed by agency staff based on the following:
1. A staff member is entering into a private professional relationship with a client because no other adequate public or
private resource is available to meet the client’s needs OR
2. A staff member had a pre-existing private professional relationship with a client prior to client receiving services from
ACBHCS.
3. A staff member had a pre-existing private professional relationship with a client prior to the effective date of this
policy.
A signed acknowledgement of this information will be retained by ACBHCS in confidential files. This data may be reviewed
in order to audit the number of clients who enter the private practice of any ACBHCS staff.
When staff agrees to enter into a private professional relationship with a client following his/her termination with ACBHCS,
this information will be provided to the ACBHCS.
When a current private professional relationship with a client exists, the following has occurred:
I have encouraged this client to return to, and appropriately terminate, any existing client/therapist relationships
before entering into one with me.
I have determined that no other public sector, private or nonprofit agency resource is available to adequately meet
the client’s needs.
I have not solicited this client’s business in any way, nor used my position in this agency to advertise my services as
an independent practitioner.
I have explicitly stated that the decision to enter such a relationship will not affect the client’s County services in any
manner, except that I will exclude myself from any decisions in the future that affect their care within the County
system, since this could represent conflict of interest.
V. PROGRAM MANAGER & SUPERVISORS WILL DO THE FOLLOWING:
Assist staff in understanding how clear boundaries in their relationships with clients serve to protect clients from
manipulation, distorted perceptions, and exploitation.
Assist staff in understanding how the terms of this policy are related to the need for clear boundaries in their
relationships with clients.
Whenever necessary, also assist staff in maintaining warm, empathetic, and humanistic relationships with clients in
a way that protects the service delivery relationship from manipulation, distorted perceptions, and (counter
transferences) exploitation.
ETHICAL CONDUCT POLICY REFERENCES
Jacobs, Brotz and Gamel, Critical Behaviors in Psychiatric Mental Health Nursing, Volume II, Behavior of Nurses,
American Institutes for Research, Palo Alto, California, 1973, pages 493-505.
International Association of Psychosocial Rehabilitation Services, Field Review Copy, Code of Ethics for Psychiatric
Rehabilitation Practitioners, International Association of Psychosocial Rehabilitation Services, Columbia, M.D..
Board of Behavioral Sciences, Laws and Regulations Relating to the Practice of Marriage, Family, and Children
Counseling, Licensed Clinical Social Work, and licensed Educational Psychology, Board of Behavioral Sciences,
Sacramento, CA, August 2000.
Balancer, Lewis and RCALP, Avoiding Criminal Law Issues in Medicare Billing (c), Phoenix, Arizona.
Alameda County Prohibition of Sexual Harassment Policy.
Alameda County Right of Equal Treatment and Respect Policy.
Alameda County Client Privacy and Confidentially Policy.
Alameda County Contractor’s Policy. (Tentative)
Alameda County Workplace Violence Policy.
MOU Mutual Respect Clause.
ROSTER: Credentials Committee
Peter Alevizos, Ph.D., M.B.A.
Richard Singer, M.D.
Carolyn Novosel, LCSW
Damon Bennett, LCSW
Dean Chambers, LCSW
ACKNOWLEDGEMENT
I hereby acknowledge that I have reviewed and understand Sections 1 through 5 of the ACBHCS Ethical Conduct Policy.
I certify that I have read, understand, accept, and agree to act in accordance with this statement of policy, requirements and
/or conditions/terms of employment.