All new hires will take each individual core competency exam or comprehensive new hire exam Patient Safety Goals Basic RT exam and checklist

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1 Respiratory Respiratory Therapist A respiratory therapy technician provides professional respiratory care to patients that have had an acute event as a result of an illness, injury, or exacerbation of a disease process. The respiratory therapist technician will utilize: professional respiratory therapy assessment and treatment skills, documentation, communication skills, and clinical skills in collaboration with physicians and other team members. A RT is responsible for planning, organizing, and evaluating care interventions and their effect on outcome. They support staff, patients, and family education to enhance knowledge, skills and necessary behaviors to facilitate positive outcomes. Basic Exams and Checklist: Core Competencies All new hires will take each individual core competency exam or comprehensive new hire exam Patient Safety Goals Basic RT exam and checklist Specialty Exams and Checklists: ICU/ER PICU/NICU SIGNATURE DATE Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: Fax: achievemedical@att.net Achievemedicalstaffing.com

2 DRUG AND ALCOHOL POLICY Achieve Medical Staffing strives to provide a safe work environment for our employees and our clients. Concerning this, the company considers the abuse of drugs or alcohol on the job to be an unsafe and counter productive work practice. It is, therefore, company policy that an employee found with the presence of alcohol or illegal drugs in his/her system, in possession of, using, selling, trading, or offering for sale illegal drugs or alcohol during working hours, will be subject to disciplinary action including discharge. Substance Abuse includes possession, use, purchase or sale of drugs or alcohol on company or client premises, (including the parking lots). It also includes reporting to work under the influence of drugs or alcohol. An employee reporting for work visibly impaired is unable to properly perform required duties and will not be allowed to work. Prescription drugs prescribed by the employee's physician may be taken during work hours. The employee should notify the company s management personnel if the use of properly prescription drugs will affect the employee's work performance. Abuse of prescription drugs will not be tolerated. It is our responsibility as a company to counsel with an employee whenever we see changes in performance that suggests an employee problem. Employees will be required to submit to drug and/or alcohol testing at a laboratory chosen by the company if there is a cause for reasonable suspicion of substance abuse. Employees who refuse substance testing under these circumstances will be terminated. Circumstances that could be indicators of a substance abuse problem and considered reasonable suspicion are: 1. Observed alcohol or drug abuse during work hours on company premises. 2. Apparent physical state of impairment. 3. Incoherent mental state. 4. Marked changes in personal behavior that is otherwise unexplainable. 5. Deteriorating work performance that is not attributed to other factors. 6. Accidents or other actions that provide reasonable cause to believe the employee may be under the influence. 7. Or as required by any government programs such as the US Department of Transportation. If the test results are positive then termination will result. Employees who refuse substance testing under these circumstances will be terminated. Employee Signature: Date: Achieve Medical Staffing Drug and Alcohol Free Policy

3 Drug Testing Consent Form I have applied for employment with Achieve Medical Staffing. As a condition for my application being considered, I understand and agree to undergo substance screening. I understand that if my test results are positive, I shall not be considered further. I here authorize any physician, laboratory, hospital or medical professional retained by Achieve Medical Staffing for screening purposes to conduct such screening and to provide the results to Achieve Medical Staffing, and I release Achieve Medical Staffing and any person affiliated from liability therefore. Applicant s name printed Applicant s Signature Date

4 FIT TEST: o Provide employee with a glass of water in order to cleanse the mouth of saccharin residue. o o o o Wipe out the inside of the lit test hood with damp cloth to remove saccharin residue. Instruct/assist the employee in donning the respirator. Place hood over the employee s head and position it at least six inches from the face. Instruct the employee to breathe through the mouth and begin the following test exercises: Using Neutralizer #2, apply squeezes during each of the following six activities equal to one- half of the Sensitivity number. 50% of Sensitivity #: Is the employee able to taste saccharin as detected during the Sensitivity Test while: CHECK ONE o Breathing normally for 60 seconds o Breathing deeply for 60 seconds o Turning head side to side for 60 seconds o Nodding head up and down for 60 seconds o Resuming normal breathing for 60 seconds If YES was checked above for any of the six activities the employee must be tested again after re- adjusting the respirator or trying a different size. PASS FAIL SIZE: SMALL REGULAR Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: FAX:

5 Safe use of respiratory equipment is the responsibility of the user. Re- testing shall be performed in the event of a weight change of 20 pounds or more, significant facial scarring, significant dental changes, cosmetic surgery, or any other change, which may adversely affect respirator sealing. It is the responsibility of the wearer to inform their supervisor of the Occupational Health Clinic of any of the above types of changes. Note: TB respirator masks cannot be properly fitted to staff wearing facial hair growing across mask seal area. Print Name: Signature: DATE: Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: FAX:

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7 HIPPA ACKNOWLEDGEMENT & EMPLOYEE CONFIDENTIALITY I,, an employee of Achieve Medical Staffing, acknowledge the confidentiality of patient health information ( Confidential Patient Information ) that I may receive or have access to in the course of providing patient care services at participating healthcare facilities at which I am assigned. Patient and personnel information is permitted only on a need- to- know basis. It is the policy of Achieve Medical Staffing and the healthcare facilities Achieve Medical Staffing serves, that all users respect and preserve this right to privacy and confidentiality. Violations of this policy include, but are not limited to: Accessing information that is not within the scope of your job Disclosing, misusing without proper authorization, or altering patient or personnel information Disclosing your sign- on code and password or using another person s sign- on code and password for accessing electronic or computerized records Leaving a secured application unattended while logged on Attempting to access a secured application without proper authorization Violations of this policy may constitute grounds for disciplinary action up to and including termination of employment or loss of hospital privileges in accordance with hospital procedures and/or federal or state laws and regulations, including without limitation, the privacy provisions under Health Insurance Portability and Accountability of 1996 ( HIPPA ) and the policies and procedures of each participating healthcare facility where I am assigned. My agreement to maintain the confidentiality of Confidential Patient Information shall survive the termination of my employment with Achieve Medical Staffing, and the conclusion of any assignment at the participating healthcare facility. APPLICANT NAME: DATE: SIGNATURE:

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15 POST-HIRE MEDICAL HISTORY QUESTIONNAIRE WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. Please check in the appropriate space whether or not you currently have or have previously had any of the following conditions: Epilepsy Headaches Diabetes Head Pain Heart Disease Hyperinsulism Arthritis Muscular Dystrophy Amputated foot, leg, arm or hand or loss of use there of Arteriosclerosis Loss of sight, partial or total Thrombophlebitis Double vision or blurred sight Pain and/or stiffness in finger(s) Poliomyelitis Heavy metal poisoning Cerebral Palsy Brain Damage Multiple Sclerosis Discectomy Parkinson s Disease Spinal Fusion Stroke Surgical Removal of Lumbar or Cervical Disc Tuberculosis Cervical Fusion Silicosis Asbestosis Mental Disability Hemophilia Knee Pain Knee Soreness Shooting Pains Numbness EMPLOYEE SIGNATURE: DATE: Administrator s Initials Page 1

16 WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. Osteomyelitis Tingling Head Injury Dizziness Nervous Breakdown, Anxiety or Depression High Blood Pressure Ionizing Radiation Injury Rotator Cuff Injury Compressed Air Sequelae Pain and/or stiffness in toe(s) Bronchitis Sore Neck Emphysema Neck Pain Asthma Neck Ache Ruptured Disc(s) Sore Disk Bulging Disc(s) Tingling sensation in arms, legs, fingers, or toes Leg Pain Leg Soreness Fractured or broken bones Difficulty Lifting Difficulty Stooping Difficulty bending Shooting pains down from back through lower extremities Shooting pains down from neck or upper back through arms Back Pain Back Ache Difficulty Moving Neck Difficulty Moving Back Knee Injury Loss of consciousness Difficulty moving lower extremities Difficulty moving knees Knee stiffness Back stiffness EMPLOYEE SIGNATURE: DATE: Administrator s Initials Page 2

17 WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. Hodgkin s Disease Mental Retardation Carpal tunnel syndrome Hypertension Pain and/or stiffness in hand(s) Neck Stiffness Neck injury or neck symptoms Back injury or back symptoms Varicose veins Shoulder pain Foot ailment/pain Pain and/or stiffness in wrist(s) Arthroscopy Hearing loss If you answered YES to any of the conditions, please explain below the nature of your injury, condition, or the type of treatment received, the name, address and phone number of the doctor providing the treatment and any impairment or disability that may have been assigned as a result of injury. EMPLOYEE SIGNATURE: DATE: Administrator s Initials Page 3

18 WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. Has any doctor ever restricted your activities? If you answered YES, please list the medical condition, type of restrictions placed, whether these restrictions were temporary or permanent, and whether you are presently under these restrictions. Have you ever been assessed any percentage of permanent disability to any part of your body for any reason whatsoever? If YES, please explain: Are you presently under any medical treatment by a doctor, chiropractor, psychiatrist, psychologist or other health care provider? If you answered YES please list the medical condition(s) being treated, the name of the doctor(s), field of specialty, address and telephone number. Are you presently taking any medication? If you answered YES, please list the name of the medication, the medical condition being treated, and the name, address and telephone number of the doctor who prescribed the medication. EMPLOYEE SIGNATURE: DATE: Administrator s Initials Page 4

19 WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. Have you ever had surgery to any part of your body? If you answered YES, please list the part(s) of the body operated on, the type of operation performed, the date of the operation, the name of the hospital, if any, where the operation was performed, and the name, address and phone number of the doctor performing the surgery. Have you ever received treatment for your back, neck, knees or lower extremities from a doctor, chiropractor, therapist or other health care provider? If you answered YES, please list the name, address and phone number of all doctors, chiropractors, therapists or other health care providers who provided such treatment, the dates of the treatment and the diagnosis provided. Have you ever had an injury which required you to miss time from work? If you answered YES please list the type of injury, the amount of time missed from work, whether the condition was fully resolved or if it left you with any impairment, and whether you returned to work. Are you aware of any condition or injury that might impair or limit your ability to work for this company? If you answered YES, please describe the condition or injury. EMPLOYEE SIGNATURE: DATE: Administrator s Initials Page 5

20 WARNING PURSUANT TO LSA-RS 23:1208 AND OF THE LOUISIANA WORKERS COMPENSATION ACT, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTFULLY ANY OF THE QUESTIONS BELOW SHALL RESULT IN (1) A FINE OF NOT MORE THAN FIVE HUNDREED DOLLARS OR IMPRISONMENT FOR NOT MORE THAN TWELVE MONTHS, OR BOTH AND (2) A FORFEITURE OF COMPENSATION AND MEDICAL BENEFITS UNDER THE LOUISANA WORKERS COMPENSATION ACT. I HAVE READ AND FULLY UNDERSTAND THE ABOVE. EMPLOYEE SIGNATURE: DATE: Employer s inquiry into employee s previous injury claims: Forfeiture of Benefits Nothing in this Title shall prohibit an employer from inquiring about previous injuries, disabilities, or other medical conditions and the employee shall answer truthfully; failure to answer truthfully shall result in the employee s forfeiture of benefits under this Chapter, provided said failure to answer directly relates to the medical condition for which a claim for benefits is made or affects the employer s ability to receive reimbursement from the second injury fund. This section shall not be enforceable unless the written form on which the inquiries about previous medical conditions are made contains a notice advising the employee that his failure to answer truthfully may result in his forfeiture or workers compensation benefits under R.RS. 23: Such notice shall be prominently displayed in bold0faced block lettering of no less than ten point type. Administrator s Initials Page 6

21 Employee Name: Respirator Medical Evaluation Questionnaire To the employer: Answer to questions in Section 1 and to question 9 in Section 2 of Part A do NOT require a medical examination. To the employee: Can you read? Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it. PART A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator must provide the following information. Name: Title: Age: Sex: MALE FEMALE Height: ft. in. Weight: Please list a phone number where the health care professional who reviews this questionnaire can reach you. Phone: Best time to reach you: Has your employer told you how to contact the heath care professional who will review this questionnaire? (Check One) YES NO Check the type of respirator you will use: (You may check more than one category) A. N, R, or P disposable respirator (filter- mask, non- cartridge type only). B. Other type (for example, half- or full- face piece type, powered- air purifying, supplied- air, self- contained breathing apparatus). Have you worn a respirator? (Check One) YES NO Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: Fax:

22 If yes, what type? PART A. Section 2. (Mandatory) Questions 1-9 below must be answered by every employee who has been selected to use any type of respirator. (Please check Yes or No) 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: 2. Have you ever had any of the following conditions? A) Seizures: B) Diabetes: C) Trouble smelling odors: D) Claustrophobia: E) Allergic reactions that affect your breathing: 3. Have you ever had any of the following pulmonary or lung problems? A) Asbestosis: B) Asthma: C) Emphysema: D) Pneumonia: E) Tuberculosis: F) Silicosis: G) Pneumothorax: H) Lung Cancer: I) Chronic Bronchitis: J) Broken Ribs: K) Any chest injuries or surgeries: L) Any other lung problem: 4. Do you currently have nay of the following symptoms of pulmonary or lung illness? Please Circle Yes or No. A) Shortness of breath: YES NO B) Shortness of breath when walking fast on level ground or walking up a slight hill or incline YES NO C) Shortness of breath when walking with other people at an ordinary pace on level ground YES NO D) Have to stop for breath when walking at your own pace on level ground YES NO Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: Fax:

23 E) Shortness of breath when washing or dressing yourself YES NO F) Shortness of breath that interferes with your job YES NO G) Coughing that produces phlegm (thick sputum) YES NO H) Coughing that wakes you early in the morning YES NO I) Coughing that occurs mostly when you are lying down YES NO J) Coughing up blood in the last month YES NO K) Wheezing YES NO L) Wheezing that interferes with your job YES NO M) Chest pain when you breathe deeply YES NO N) Any other symptoms that you think may be related to lung problems YES NO 5. Have you eve had nay of the following cardiovascular or heart problems? (Please Check Yes or No) A) Heart Attack: B) Stroke: C) Angina: D) Heart Failure: E) Swelling in your legs or feet (not caused by walking) F) Heart Arrhythmia (heart beating irregularly) G) High Blood Pressure H) Any other heart problem I) Have you ever had any of the following cardiovascular or heart symptoms: J) Frequent pain or tightness in your chest: K) Pain or tightness in your chest during physical activity: L) Pain or tightness in your chest that interferes with your job: M) In the past two years, have you noticed your heart skipping or missing a beat: N) Heartburn or indigestion that is not related to eating: 6. Any other symptoms that you think may be related to heart or circulation problems? 7. Do you currently take medication for any of the following problems: A) Breathing or lung problems: B) Heart trouble: C) Blood pressure: D) Seizures: 8. If you ve used a respirator, have you ever had any of the following problems? (If you ve never used a respirator, check the following space and go to question 9: Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: Fax:

24 Never used A) Eye irritation: B) Skin allergies or rashes: C) Anxiety: D) General weakness or fatigue: E) Any other problem that interferes with your uses of a respirator 9. Would you like to talk to the health care professional that will review this questionnaire? Comments (for Health care professional only) Signature: DATE: Achieve Medical Staffing P.O. Box 159, Dry Prong, LA Phone: Fax:

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