24 Hour Staffing Solutions
24 Hour Solutions Inc.
Staffing
Agency
415-648-6091
Name
___________________________________________________________
Date: _________________ Phone No.
____________
q An Agreement
Between Contractor And 24 Hour Staffing Solutions Nursing Agency
q Annual
Health Survery
q Annual
Tuberculosis Questionnaire
q Application
Filled
q Authorization
For Employment Validation
q Background
Check Consent Form
q Current
CPR (ACLS, PALS, if needed)
q Current
License
q Domestic
Violence, and Suspected Abuse Sheets
q Employment
Validation
q Exams
q Hepatitis
B Declination Statement
q HIPAA
q Contractor Policy
q Pt.
Confidentiality Agreement
q Skills
Checklist
q Social
Security Card
q Time
Card
q Varicella
Questionnaire
q W-9 for
Contractor
q I-9
Documentation
Healthcare Provider Signature ________________________ Date
________________
24 Hour Staffing Solutions
Staffing Agency
“An Agreement between Contractor and 24 Hour Staffing Solutions”
1.
The undersigned individual is a, please circle and initial one:
a. Registered Nurse d. Medical Assistant
b. License Vocational Nurse e.
Administrative Assistant
c. Certified Nursing Assistant f.
Sitter
wishes to enter into a non-exclusive placement
contract with 24 Hour Staffing Solutions to have it find limited contractual
engagements for healthcare work for which the Undersigned holds the applicable
license.
2.
The undersigned individual, referred to as Healthcare Provider.
throughout the rest of this agreement understands that this engagement is as
independent contractor, and not as an employee of 24 Hour Staffing Solutions or
a contracting (client) Nursing Home/Hospital/Surgical Center/Clinic. As such, the Healthcare Provider. understands
that he or she will be solely responsible for all payment of income and
self-employment taxes. No taxes will be
held from the Healthcare Provider’s income.
24 Hour Staffing Solutions will report all income over $600.00 per year
or over to the Internal Revenue Service and the State California, and will
provide the Healthcare Provider with a form 1099 for their records, to assist
them in filing their taxes.
3.
24 Hour Staffing Solutions shall act solely as contracting agent to
sub-contract nurses to the Nursing Homes/Hospital/Surgical Centers/Clinic.
4.
24 Hour Staffing Solutions is being compensated for the service of the
Healthcare Provider, and the Healthcare Provider appoints 24 Hour Staffing
Solutions as his/her agent to find contracts for him/her and to receive
compensation on his/her behalf. The agency
appointment by the Healthcare Provider is irrevocable as to that particular
contract. 24 Hour Staffing Solutions
agrees to pay the Healthcare Provider for his/her time depending on each facility’s rate. The Healthcare Provider shall be paid time and
a half after eight (8) hours only if authorized by the facility. Otherwise straight time will only be paid
over eight (8) hours of work. Payment
shall be made every week.
5.
24 Hour Staffing Solutions agrees to pay
6.
The Healthcare Provider agrees not to perform duties at the Nursing
Home/Hospital/Surgical Centers/Clinic outside the scope of his/her license.
7.
Each Healthcare Provider represents to 24 Hour Staffing Solutions that:
A The
Healthcare Provider is licensed or certified in the State of California to
perform the type of work for which they are place to, and their license or
certification is not suspended or revoked, and has never been suspended or
revoked.
B The
Healthcare Provider carries malpractice insurance in the amount of at least one
million U.S. dollars if a Registered or License Vocational Nurse and for the
premiums have been paid. The Healthcare
Provider carries malpractice insurance in the amount of at least five hundred
thousand U.S. dollars if a nursing assistants and for which the premiums have
been paid.
C The
Healthcare Provider is not covered by worker’s compensation insurance through
24 Hour Staffing Solutions for being an independent contractor.
D.
The Healthcare Provider has a minimum of one year experience in one of
the following six types of Healthcare Provider indicated above.
E. The
Healthcare Provider agrees that unless they are told otherwise, they are to
wear standard white attire (scrubs if allowed by facility), including ID
nametag and a transfer belt while on contract.
F. The
Healthcare Provider authorized 24 Hour Staffing Solutions to deduct necessary
payments for the Malpractice Insurance from the Nurse's pay, statement of
deductions and an annual summary shall be supplied by 24 Hour Staffing
Solutions, to the Healthcare Provider.
8.
The Healthcare Provider agrees to supply any information necessary to
insure that 24 Hour Staffing Solutions is meeting its contractual obligation to
the Nursing Homes, Clinics, Hospitals, and/or Surgical Centers, such as any
disciplinary proceedings initiated against the Healthcare Provider, malpractice
coverage documents, employment history, etc.
8. The
Healthcare Provider understands that he/she is not to provide services in a private
home under any contract for which she sent by 24 Hour Staffing Solutions.
9.
The Healthcare Provider agrees to supply the time card, signed by the
authorized Nursing Home/Hospital/Surgical Center/Clinic Representative every
Monday before 5 pm to 24 Hour Staffing Solutions or he/she will not be paid on
time.
10.
The Healthcare Provider agrees that the 24 Hour Staffing Solutions is not
responsible for any employment or lack of employment.
11.
If a Nursing Home/Hospital/Surgical Center/Clinic (client) cancels within
two hours of a scheduled shift and the Healthcare Provider is unable to be
placed anywhere else, the Healthcare Provider will be paid two hours. If a Nursing Home/Hospital/Surgical
Center/Clinic (client) cancels more than two hours before the beginning of a
shift, the Healthcare Provider will not receive any compensation even if he/she
is not informed of the cancellation. The
Healthcare Provider must verify one and one half hours (1.5) before the start of the shift.
12.
If a Healthcare Provider fails to show up for work, or cancels within
four hours, the Healthcare Provider agrees to reimburse 24 Hour Staffing
Solutions for an amount of equal to two hours of the pay by deductions from
payroll.
13.
The Healthcare Provider understand that he/she must notify the agency
before applying for the facility that 24 Hours Staffing Solutions has a
contract with.
14.
24 Hour Staffing Solutions is not responsible for the Healthcare
Provider’s transportation problem or any other issues that may come across
during his/her travel to facility.
15.
The Healthcare Provider has an absolute right to accept or reject any
contract for any reason whatsoever, but once a contract is accepted, the
Healthcare Provider agrees that he/she or another Healthcare Provider will show
up at the appointed time. The Healthcare
Provider is free to subcontract with any Healthcare Provider which is
registered with 24 Hour Staffing Solutions in advance, and who is acceptable to
the Nursing Home/Hospital/Surgical Center/Clinic
14. This agreement is to be
construed under laws of the State of
I agree to this contract and understand its terms. I have a _____________ license as is
indicated above and carry the correct amount of malpractice insurance.
Name_______________________________________________
Address______________________________________________
Social Security No.____________________________________
Nurse Signature_________________________________________ Date____________
Authorized Representative of 24 Hr. Staffing Sol. ____________________________
Date_____________
Staffing Agency
|
This
Health Survey is a 24 Hour Staffing Solutions ANNUAL REQUIREMENT and is
intended to be a work-related assessment of my ability to perform without
limitation. I certify that the answers
to all survey questions are true and understand employment may be withdrawn
or terminated due to misrepresentation, omission or falsification |
SINCE COMPLETING YOUR LAST HEALTH SURVEY HAVE YOU EXPERIENCED ANY OF THE FOLLOWING
|
Alcohol Abuse? Y N |
Hernia? Y N |
Small Pox? Y N |
|
Allergies? Y N |
High Blood Pressure? Y N |
Sprains? Y N |
|
Arthritis? Y N |
Immune System Disorder?
Y N |
Stomach Disorders?
Y N |
|
Asthma?
Y N |
Jaundice? Y N |
Tuberculosis? Y N |
|
Back Strain? Y N |
Kidney Disease? Y N |
Urinary Tract Infection?
Y N |
|
Back Surgery? Y N |
Kidney Stone? Y N |
Ulcers: peptic? Y N |
|
Broken bones? Y N |
Liver Disease? Y N |
Venereal Disease?
Y N |
|
Bronchitis? Y N |
Malaria? Y
N |
Please explain each yes answer. |
|
Cancer? Y N |
Mental Conditions? Y N |
_______________________ |
|
Cardiovascular Trouble? Y
N |
Migraine headaches? Y N |
_______________________ |
|
Diabetes? Y N |
Nervous Condition? Y N |
_______________________ |
|
Dislocations? Y N |
Pneumonia? Y N |
_______________________ |
|
Epilepsy? Y N |
Psychological Condition? Y
N |
_______________________ |
|
Fainting spells? Y N |
Rheumatism? Y N |
_______________________ |
|
Hay fever? Y N |
Seizures? Y N |
_______________________ |
|
Hepatitis A? Y N |
Sinus problem? Y N |
_______________________ |
|
Hepatitis B? Y N |
Skin Disease? Y N |
|
SINCE COMPLETING MY LAST 24 HOUR STAFFFING SOLUTIONS HEALTH
SURVERY HAS ANY OF THE FOLLOWING INFORMATION CHANGED/PROVIDED.
|
ALLERGIES |
IMMUNIZATIONS |
TB
STATUS |
PHYSICIAN
DESIGNATION |
|
Report known: |
Tetanus? |
The date of my last PPD: |
Name: |
|
|
Gamma Globulin? Y___ N ___ |
Month:
Year: |
Address: |
|
|
Hepatitis B Immune Globulin? Y __
N __ |
My last CXR was performed: |
|
|
|
Series completed? |
Month: Year: |
Telephone: |
|
|
|
|
|
The date of my last physical was: _________________ Month: _______________ Year: ____________
The name and address of the physician and/or facility that
performed the physical:
Name: ________________________________________________ Telephone: ____________________
Address:
Do you have any physical defects / limitations which
precludes you from performing certain job / responsibilities?
Y N
Is there pending, or have you applied for a pension, or
compensation for any existing disability? Y N
I certify that the answers to all health survey questions
are true and understand employment/contracting may be withdrawn, or terminated
due to misrepresentation, omission or falsification.
____________________________________ ____________________________ _________________
Print Name Signature Date
24
Hour Staffing Solutions
Staffing Agency
ANNUAL PHYSICIAN STATEMENT OF HEALTH CLEARANCE
|
The physician Statement of
Health Clearance is a 24 Hour Staffing Solutions Annual Employment
Requirement to be completed on or by my anniversary date to meet 24 Hour
Staffing Solutions Standards for Employment and active status. The Health is intended to be a work related
statement of my ability to perform without limitations. |
PHYSICIAN INFORMATION
Physician Print Name: _______________________________________________
License Number: _______________________________ State Of: __________________
The medical record will show I conducted a history and physical on: ___/___/____
FINDINGS: To the best of my knowledge, the individual named below is in good physical and mental health and is free of any communicable disease. This individual has no apparent health condition that would create a hazard to self or other and is able to function at full without limitation.
Impressions: ___________________________________________________________
Physician Signature: ____________________________ Date: ____________________
Address:
_________________________________________________
|
In accordance with state,
federal laws and regulations, 24 Hour Staffing Solutions. and its Clients
will identify vaccines, titers and other tests required of each individual. Please provide copies of
the laboratory results for this individual, available in the medical record and
for the purpose of this Annual Health Clearance. |
CONTRACTOR
INFORMATION:
Print
Name: _________________________________
Signature: ___________________
24
Hour Staffing Rep. Signature: ____________________________ Date: ___________
The
Americans with Disabilities Act, at 42 USC Sec. 12112 (d)(3)(B) requires
employers to keep information relating to medical condition on separate forms
and in medical files separate from general personnel information. This requirement is mirrored by the Family
and Medical Leave Act of 1993 [See 29 CFR Sec. 825.500 (g)] and in the
California Confidentiality of Medical Information Act {Civil Code Sec. 56-56.36}
24
Hour Staffing Solutions
Staffing Agency
ANNUAL TUBERCULOSIS QUESTIONNAIRE
|
This TB Questionnaire is a 24 Hour Staffing
Solutions Annual requirement and a
method to monitor infection control and reportable disease. The incidence of Tuberculosis (TB) and drug
resistant strains is an increasing occurrence in the |
HEALTH HISTORY
1.
Are you currently pregnant?
Y N
2.
Have you received any vaccines in the last six
weeks? (i.e. mumps, measles,
rubella? Y N
3.
Have you had a viral, fungal, or bacterial infection
within the last month?
Y N
4.
Have you been treated with steroids, corticosteroids
or immunosuppressive agents?
Y N
5.
Have you had pneumonia or bronchitis in the past
year? Y N
6.
Are you experiencing a productive, prolonged
cough?
Y N
7.
Are you experiencing chest pains?
Y N
8.
Are you experiencing hemoptysis (coughing up
blood)?
Y N
9.
Are you experiencing a fever that persists?
Y N
10.
Are you experiencing chills that recur?
Y N
11.
Are you experiencing night sweats?
Y N
12.
Are you experiencing fatigue – easily and
ongoing?
Y N
13.
Are you experiencing an unexplained weight loss?
Y N
14. Are you experiencing an unexplained weight loss?