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*Please provide your c+Contractor Number (e.g. c012345) or e+Employee Number (e.g. e123456) for 'Re - Assignment', 'Additional Position', 'Transfer', 'County Rotation'.
*Employee No.
*Sponsor Facility:
*Sponsor Division:
*Sponsor Name:
As appeared on your identification card:
Other Name(s) Used:
Marital Status:
*Ethnicity:
(Name and location of School)
Last Grade Completed
Date Completed
College
Major
Degrees or
Diploma
From Mo-Yr
To
Mo-Yr
Time In Mo.
Position or Occupation
Duties performed
Name and addresses of all former employers including other County depts. as well as private firms
Reason for Leaving
If yes, please provide details but do not include criminal conviction information. (REQUIRED, limited 500 characters)
PARENTAL CONSENT FOR MINORS
A.
I have read this form "Parental Consent for Health Evaluation" and given Los Angeles County Department of Health Services permission
to conduct a criminal background check, obtain medical information and/or provide medical care/screening for a minor applicant.
Parent or legal responsible person must sign "Parental Consent for Health Evaluation" form in the presence of DHS Human Resources
staff and show identification. Print out this form and bring it with you to Human Resources for in-processing.
Click here to read
CONDITION OF ASSIGNMENT FORMS (Check One)
1.
I have read the form "Acknowledgment of Conditions of Assignment (Voluntary Attending Staff)" and I agree to the conditions of the County assignment listed.
Click here to read.
LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 1a.)
1a.
As a Voluntary Attending Staff member, I am an officially enrolled Volunteer of the County, and I understand that the County will defend and insure me against any
liability resulting from an act or omission occurring during the course and within the scope of my practice within any County facility. I also understand, however,
that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.
2.
I have read the form "Acknowledgment of Conditions of Assignment (Contract/Registry Staff, Non-County Residents/Fellows/Affiliates)" and I agree to the conditions of the County assignment listed.
Click here to read.
LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 2a.)
2a.
I am a Contract/Registry Staff, Non-County Resident/Fellow/Affiliate, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my employer or academic institution, unless otherwise contractually provided, and the County of Los Angeles shall be held harmless and will not defend or insure me in any action taken against me as a result of my acts or omissions, whether conducted within, or outside of, my approved scope of practice, within any County facility.
3.
I have read the form "Acknowledgment of Conditions of Assignment (Volunteers, Students)" and I agree to the conditions of the County assignment listed.
Click here to read.
LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Choose the statement that applies to you)
3a.
I am a student, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my sponsoring academic institution, agency or employer, unless otherwise contractually provided. The County of Los Angeles shall be held harmless and will not defend or insure me against any liability resulting from any act of omission whether arising within, or outside of, the course of scope of my assignment.
3b.
I am an officially enrolled Volunteer of the Los Angeles County Department of Health Services, and I understand that the County will defend and insure me against any liability resulting from an act or omission occurring during the course and scope of my volunteer work assignment. I also understand, however, that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.
4.
I have read the form "Acknowledgment of Conditions of Assignment (Independent Contractors)" and I agree to the conditions of the County assignment listed.
Click here to read.
LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 4a.)
4a.
I am an Independent Contractor, and I understand I am responsible for providing and maintaining each of the types and limits of commercial insurance coverage which are specified by the terms of my County service agreement/contract unless otherwise provided or waived by the County. The County of Los Angeles shall be held harmless and will not defend in any action taken against me as a result of my activities within any County facility.
SCOPE OF ASSIGNMENT (Check One)
The scope of my assignment involves direct patient care activities for which I will maintain current licensure, certification, registration, and/or permit without restriction and provide adherence to the appropriate authorities at the medical center or facility.
The scope of my assignment does not involve direct patient care duties, although if my assignment requires licensure, certification, registration and/or permit, I will keep it current and without restriction.
MANDATORY FORMS [ALL CHECKBOXES MUST BE CHECKED]
*5.
I have read the "Non-County Workforce Comprehensive Policy Statement (CPS)" and agree to abide by the contents.
Click here to read.
*6.
I have read the "Code of Conduct" guidance from DHS Compliance Program and acknowledge the standards and principles for ethical and legal conduct. I acknowledge that I will complete the online Compliance Awareness Training within 60 days of my assignment date.
Click here to read.
*7.
I have read the "Patient Privacy & Confidentiality Packet" and agree to abide by the policies and procedures. I will complete the online Privacy & Security Survival Handbook within 60 days of my assignment.
Click here to read.
*8.
I have read the County Policy of Equity and agree to adhere to the County Policy of Equity.
Click here to read.
*11.
I have read the "Risk Management & Employee Patient Safety Handbook" and agree to abide by the contents of the handbook.
Click here to read.
*12.
I have read the “Background Investigation Policy” and agree to the conditions set forth in the policy related to a Non-County assignment.
Click here to read.
*13.
I have read the “Acceptable Use and Confidentiality agreement of County’s Information Technology Assets, Computers, Networks,
Systems and Data” and agree to adhere and abide by the Acceptable Use Agreement.
Click here to read.
*15.
I understand my assignment to a Non-County staff position is contingent on successfully passing the Live Scan criminal background investigation
and health screening.
*16.
I have read the orientation/re-orientation handbook for the facility in which I have been assigned. If I have any questions,
I will consult with my supervisor/sponsor.
*17.
To the best of my knowledge, I am not currently being excluded or suspended from participating in a federally-funded or State health care program (Medicare, Medicaid, or Medi-Cal) nor have I opted out of Medicare.
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I CERTIFY THAT ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
* Required Field