health professionals’ services program ... - hpsp monitoring...hpsp requires the following safe...
Post on 29-Jan-2021
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IBH Health Professionals’ Services Program 1220 SW Morrison St. #600
Portland, Oregon 97205-2126 1.888.802.2843
Fax: 503.961.7142 Hpspmonitoring.com
Health Professionals’ Services Program Workplace Monitor Safe Practice Report
HPSP requires the following safe practice report form be completed by the workplace monitor and that the form be sent directly to IBH HPSP. This form must be submitted on a monthly basis in order for the Licensee to be in compliance with his/her monitoring agreement. Please either mail or fax this form to IBH by the close of business on the 5th day of each month. If in between the reporting time period there is any evidence of unsafe job performance or any concerns please contact IBH immediately at 1-888-802-2843. This is a confidential document and only should be viewed by staff with a need to know.
Licensee Name or account#: _____________________________ Evaluation From: ______ To: ______
Employment Setting: Name of Employer: _________________________________ Workplace setting: _______________________________________
Confidential fax__________________________ Email address:______________________________________________________
Job Specifications: Has there been a change in the licensee’s position or job description since the last report? (Check One) yes no Current Position Title: ______________________________ Start date if new position: _____________ Work Hours/Shift: __________________________________________________________________________________________ Frequency of contact w/ Licensee: (Check One) daily, twice a week, weekly, every other week, monthly
Physical performance
• Balance
• Manual coordination/tremor
• Speech patterns
• Gait/stance
Within acceptable limits for workplace
Yes or No
Cognitive performance
• Mental alertness/concentration
• Memory
• Accuracy of documentation
Within acceptable limits for workplace
Yes or No
Communication performance
• Emotional tone with co-workers and patients
• Response to feedback on performance
• Maintenance of clear professional boundaries
Meets Worksite Standard
Yes or No
Attendance
• Consistent attendance without change in pattern
• No unexplained absences
Meets Worksite Standard
Yes or No
Management of Worksite Medications, if applicable
• Medication administration/documentation consistency
• Adherence to narcotic disposal policy
• Authorized access to controlled medication
Meets Worksite Standard
Yes or No NA
Please describe any behavioral changes since last report:
Comments including any concerns expressed by others pertaining to the licensee’s practice:
Paste Image of Signature Here: _________________ OR Type Name Here in Lieu of Signature :__________________ Date: _____
Print Name: __________________________________ Title: ____________________________________
Would you like to speak with the licensee’s agreement monitor? (Check One) Yes No
Name of Workplace Supervisor/Primary Workplace Monitor: ________________________ Telephone: _____________________
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