VERIFICATION CHECKLIST
for
Registry / Contract / Temporary Staff
The following Orientation and Education requirements and documents must be completed at the agency in order to work
at UCLA Health as a registry, contract or temporary staff member:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Copy of completed Agency Application
Verification of (3) signed Abuse Reporting Statements (child, domestic, elder)
Verification of signed Confidentiality Statement
Evidence of Medical Criteria Clearance/TB Testing/ Drug Screening Completion
Evidence of Background Check completion
Verification of valid License/Certification/CPR Card, including an appropriate printout from Board website (if applicable)
Verification of completed Orientation and Annual Education Module and Post Test
Verification of completed C-ICARE Training Module and Post Test
Verification of completed HIPAA Privacy and Information Security Training for New Workforce Members
Verification of completed Compliance / Code of Conduct Module and Post Test
Verification of completed Age Specific Education Module and Post Test (if applicable)
Review of Restraints Guidelines (if applicable)
Review of Sedation Guidelines (if applicable)
Review of Nondiscrimination Policies
Evidence of training in (PMAB) Prevention and Management of Assaultive Behavior (applies to RNPH Staff only)
For the two required TB tests, the first TB test must be within a year of the start date, and the second TB test must be
within 30 days of the start date. If there is a positive TB test, evidence of a clear chest x-ray must be provided. The chest
x-ray has to have been done within 3 months of the start date, and a questionnaire from a physician concerning no active
TB must be provided along with the x-ray results. The drug screening must be completed within 30 days of start date.
An original license, certification and/or CPR card must be presented to UCLA Health System personnel before starting
any assignment. These documents must be current at all times.
I, ____________________________ have completed, signed and understand the above required documents and
requirements and am ready to begin my assignment at UCLA Health System. I am aware that my personnel file can be
audited at any time by UCLA Health System Human Resources or Nursing staff for compliance purposes.
____________________________________
Temporary Staff Employee Signature
__________________
Date
____________________________________
Temporary Agency Representative (Signature)
__________________
Date
____________________________________
Temporary Agency Representative (Print)
__________________
Date
____________________________________
Agency Name
__________________
Agency Phone Number
Confirmation of valid license/CPR card (if applicable)
_______________________________________
UCLA Department Manager/Designee (Signature)
__________________
Date
____________________________________
UCLA Department Manager/Designee (Print)
__________________
Date
Temp Verif Chklst Sept. 2014