Staffing Resources Agency File Checklist & Audit Form
Name: __________________________ SSN: _____ - _____ - _____
Agency Name: ___________________ Date of Hire: __________ Rehire? □ Yes
__________ (Original Hire Date)
Yes N/A* Yes N/A*
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Application
Job Description
References Check(s)
IT Security Agreement
OIG / EPLS Sanction Report
OK Sex Offender Registry Check
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Mary Rippy Violent Crime Check
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(3) Mental Health Letters of Reference
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Motor Vehicle Report (MVR)
Current Copy of Contract
Department Orientation Checklist
Annual Competencies
Performance Review (If applicable)
CPR/ BLS
ACLS
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I-9* Form
W-4 Form
Visa Form
OSBI Stamps
Criminal Background Check
Sanction Report
– OIG
Sanction Report
Code of Conduct
License/Certification/Registry Verification (Primary Source Verification)
– EPLS
Post Position Placement Testing Results (Med Dosage exam given in PNO)
PALS
*Note RE: I-9 – Keep the I-9 for 1 year post-termination or 3 years after hire date, whichever is the greater.

Health Screening Departmental File Requirements:
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Pre-hire Physical Exam
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Hepatitis B Vaccination Series or Waiver
Negative Tuberculin Skin Test(s)* (in conformity with Oklahoma State
Department of Health’s guidelines, as expressed at Oklahoma Administrative
Code 310:667-5-4) or negative chest x-ray
□ MMR vaccinations(s) or positive titer(s), including two appropriately spaced doses of the measles and mumps vaccines or positive mumps or measles titers
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Varicella vaccination or positive titer(s)
Hepatitis A vaccination series (for Personnel working in food service and child care)
□ □ TDaP vaccination (for Personnel who may be assigned to areas that would put children under 1 year at risk for acquiring Pertussis)
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Seasonal Influenza vaccination (or declination on file citing religious and/or medical reasons)
A Negative Drug Screen (5 panel) on file within 45 days prior of Personnel’s first placement
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Employee Health Release
Fit Testing (as needed or on a just-in-time basis)
Other (as mandated by law or by INTEGRIS Health)
The INTEGRIS Health Staffing Resources Agency File Checklist & Audit Form is meant to serve as a guide for what items need to be completed PRIOR to job placement.
*N/A means not applicable for all positions
*N/A RE: TB – Two TB Tests are required; one within the last 45 days, one within the last year
Comments: ___________________________________________________________

Mandatory Annual Education Requirements:
Please visit www.integrisok.com/agency for electronic access. Annual education includes:
Airborne
Back Safety
Corporate Compliance
Bomb Threat Awareness
Yes N/A
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Electrical Safety
Emergency Preparedness
Fire Safety
General Safety
Hazardous Chemicals
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Information Security
Joint Commission Patient Safety Goals
Standard Precautions
Transmission
Workplace Violence
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Please print off the Certificate of completion for each upon completion. These education modules should be completed prior to placement and annually. Please note that INTEGRIS Health staff cannot currently access or verify completion of these modules so printing the certificate illustrates compliance.