* Required Information
CONFIDENTIALITY OF CLIENT INFORMATION
Agency personnel must read and sign their acknowledgment of the following statement: By accepting employment with Agency, I agree to carefully refrain from discussing any clients condition or personal affairs with anyone outside the agency: unless expressly authorized to do so. I will not share any medical information with other clients or visitors without clear instruction provided to the agency. I acknowledge that All information seen or heard regarding clients. dilectly or indirectly: is completely confidential and is not to be discussed, even with my family or coworkers. My job as an employee requires that I govern myself by high ethical standards. Failure to recognize the importance of confidentiality is not only a breech of professional ethics, but can also involve an employee in legal proceedings. I will not share any Infomation about clients or the agency with the media. This is essential for protection of both the client and Agency.
I have read and understood the above statement and agree to abide by these policies.
I understand that a breach of policy may result in disciplinary action and possible dismissal from employment.
Employee Name
*
Date
Witness Name
*
Date
EMPLOYEE MEDICAL INFORMATION CHECKLIST
Name
*
Date
Please choose all conditions which you have now or have had
All conditions you have now or have had
Heart Disease
Liver Problem
High Blood Problems
Poor sense of small
Epilepsy
Parasitic Infections
Anemia
Rheumatic Fever
Chronis Headache
Hepatitis
Arthritis
Visual Disturbances
Diabetes
Loss of Balance
Appendicitis
Kidney Infection
Ulcer
Comments
Employee Name
*
Date
HEPATITIS B VACCINATION CONSENT/WAIVER FORM
Name
*
Date of Birth
Social Security Number
A. Consent for Hepatitis B Vaccine
I
, consent to be immunized against Hepatitis B.
I acknowledge the following:
I have been informed that am at risk of acquiring hepatitis B because of the nature of my professional responsibilities.
I have read the information sheet that lists the indications, benefits, and presently known side effects of hepatitis B vaccine: have had an opportunity to ask questions, and have had them answered to my satisfaciion.
I must receive three (3) doses of vaccine over a period of six (6) months to confer optimal immunity
I understand, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse reaction to the vaccine.
In the event that I experience any adverse side effects or do not become immune from the vaccine I hereby hold Neighbors Keeper Home Health. harmless from any and all liabiiity to the extent permitted under the law.
In the event that I should terminate employment at Neighbors Keeper Home Health. prior to receiving all three (3) doses of hepatitis B vaccine, I understand that it will be my responsibility to complete the vaccination series on my own initiative and at my own expense.
Employee Name
*
Date
Dose/site/Lot number/Initial Number
B. Previous Immunization with Hepatitis B Vaccine
I
, have previously completed a three-dose series of the Hepatitis B at
in
Employee Name
*
Date
C. Refusal to Receive Hepatitis B Vaccine
I
, understand that due to my occupational: exposure to blood or other potentially infectious materials may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, decline hepatitis B vaccination at this time. I understand that by declining this vaccine 1 continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Employee Name
*
Date