Bring this checklist to Orientation 

New Hire Checklist 

 Tasks to be completed as soon as possible:  __ Sign and return offer letter __ Complete drug screen within 48 hours __ Sign and return Alaska State Background Check Application __ Complete and return Alaska State Background Release of Information __ Complete on‐line background check application with HireRight __ Complete and return Providence Release of Information   

Tasks to be completed prior to your start date:  __ Complete finger printing at CasTech or your local police department __ Policy verification form __ Employee Health appointment (after background check results are received) __ Provide proof of education required of job (if applicable) __ Provide proof of licensure/certification of job (if applicable)   

Bring the following to first day of new hire orientation:  __ New hire checklist (this form) __ Appropriate I‐9 identification (included in new hire packet)   

Important Numbers:  Preboarding:    (877) 554‐8484       (425) 525‐6603 Fax       hrscpreboarding@providence.org  HR Phone:    (907) 212‐6400 or (800) 478‐9940       (907) 212‐6491 Fax  HireRight:    (866)521‐6995   

EMPLOYEE INFORMATION FORM

Employee ID

Date: ______________________

Employee Name: ________________________________ SS#: ________________________

Address: ________________________________ City: ___________ State:____ Zip:________

Phone Number: ( )_______-__________ Ethnicity: ______________________

Marital Status: S M D W Foreign Language: ______________________

Veteran Status: Vietnam Era Special Disabled Veteran Other Protected Veteran

Military Status: Active Duty National Guard Reserves Spouse Of

EMERGENCY CONTACT

Name: _____________________________________ Relationship: ______________________

Address: ________________________________ City: ___________ State:____ Zip:________

Home Phone: ( )_______-__________ Work Phone: ( )_______-__________

Employee Signature: _________________________ Date: ______________________

Acknowledgement of Policies

This acknowledges that I have received, read, understand and agree to abide by the following Providence Health & Services Alaska polices:

� Badging In and Out (R620.003) � Personal Appearance, Dress and Hygiene (R600.011)� Electronic Communications (PROV-PSEC-812).

I understand that more detailed information concerning Providence policies is contained on InProv (intranet) and I am responsible for learning and complying with all policies. I further understand that Providence may change, revise, delete from or add to any policies, benefits, or practices described as it deems necessary and does so at its’ sole discretion.

______________________________ Employee Name (Please Print)

______________________________ _____________________ Employee Signature Date

Employee ID

CONFIDENTIALITY and NONDISCLOSURE STATEMENT I agree that access to confidential information within Providence Health System is a privilege. I will access and use this data only to the extent required by my responsibilities. I will not abuse access to the computer systems to examine information that is beyond my legitimate need to know. I agree to hold as confidential all information obtained from Providence Health System source (such as verbal, computer, or paper records) during the course of and following my association with Providence Health System. I understand any computer accounts and associated passwords assigned to me are for my exclusive use and are to be held in confidence. I agree not to allow any other person to use the computer system under my password. I agree to notify the Management and Information Systems Department if I have reason to believe that any other person may know my password. I understand my computer account and password will be considered my computer signature, and I will protect it accordingly. I will not disclose any proprietary or copyrighted information related to any computer application. I have reviewed the Providence Health System Policies PHS P-801 and PHS P-802, Information Security Management and Acceptable Use of Data and IT Assets. I agree to abide by these policies. I understand that willful disclosure of mine or any other user’s password to anyone other than a Management and Information Services employee constitutes misuse of a password and may be considered grounds for disciplinary action or termination. _________________________ Signature _________________________ Printed Name _________________________ Department _________________________ Date _________________________ Trainer Signature

Employee ID

New Hire Self‐Identification Form

Providence Health & Services is an Equal Opportunity Employer. We are subject to certain governmental recordkeeping and reporting requirements. In order to comply with these laws and regulations, we request employees to voluntarily complete this New Hire Self-Identification form. This form will be kept separate from your official personnel file.

Please complete the following: Name: _____________________________________________________ Hire Date: ___________________ Job Title: ___________________________________________________ Gender: Male ____ Female ____ Section I: Ethnicity / Race for EEO-1 Reporting

In order to comply with relevant civil rights laws and regulations, we request employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require information to be summarized and reported to the federal government for civil rights enforcement.

Are you Hispanic or Latino? Yes ___ No ___

If no, what race do you consider yourself to be (see reverse side for definitions)?

Section II: Disability and Veteran Status Reporting

Providence Health & Services is also subject to the Vietnam Era Veterans’ Readjustment Assistance Act, as amended, and Section 503 of the Rehabilitation Act, as amended. Our organization takes affirmative action to employ and advance in employment qualified individuals with disabilities, qualified disabled veterans, recently separated veterans, other protected veterans, and Armed Forces service medal veterans.

If you are a qualified individual with a disability, disabled veteran, recently separated veteran, other protected veteran, or Armed Forces service medal veteran as defined below, we would like to include you in our affirmative action program. If you wish to be included, please indicate your interest on this form. You may inform us of your interest to benefit under the program at this time or at any time in the future. Submission of the information below is voluntary and refusal to provide information about a disability or your veteran status will not subject you to adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require information to be summarized and reported to the federal government for civil rights enforcement.

I wish to self-identify as follows (please check all that apply):

A Disabled Veteran Yes___ No___

A Recently Separated Veteran Yes___ No___

An Armed Forces Service Medal Veteran Yes___ No___

An Other Protected Veteran Yes___ No___

A person with a physical or mental disability Yes___ No___

See section 503 of the Rehabilitation Act, as amended, for the definition of a person with a physical or mental disability. If you answered yes above and you require an accommodation to perform the essential functions of your position, you must discuss this request for accommodation with your manager or human resources. (The information on this form is used for affirmative action and statistical purposes only.)

___ White (Not Hispanic or Latino) ___ Black or African American (Not Hispanic or Latino)

___ Asian (Not Hispanic or Latino) ___ American Indian or Alaska Native (Not Hispanic or Latino)

___ Native Hawaiian or Other Pacific Islander (Not ___ Two or more races (Not Hispanic or Latino) Hispanic or Latino)

Employee ID

Employee Confidentiality and Nondisclosure Statement Name: Position: I understand that as an employee of Providence Health & Services (PH&S), I will have access to information not generally available or known to the public. I understand that such information is confidential information that belongs to PH&S. Confidential information includes but is not limited to patient, customer, member, provider, group, physician, employee, financial, and proprietary information, whether oral or recorded in any form or medium. I understand that information developed by me, alone or with others, may also be considered confidential information belonging to PH&S in accordance with PH&S policies and procedures. I will hold confidential information in strict confidence and will not disclose or use it except as authorized by PH&S, for Providence Health & Services' benefit. I will not access Confidential Information for which I have no legitimate need to know. I understand it is my responsibility to become familiar with and abide by applicable laws, regulations, and PH&S policies and protocols regarding the confidentiality and security of confidential information. I understand that e-mail is not a secure, confidential method of communication. I will not include confidential patient information in e-mail communications outside of Providence Health & Services (i.e. from or to non- providence.org e-mail addresses, without first contacting the Privacy Officer or the Information Security Officer for current protection method information). I understand that PH&S electronic communication technologies (Internet and e-mail) are intended for job-related activities, however limited personal use is permitted. Personal use is determined as incidental and occasional use of electronic communications technologies for personal activities that should normally be conducted during personal time, such as break periods, or before and after scheduled working hours, and is not in conflict with business requirements of the department. Internet usage is monitored and audited on a regular basis by PH&S management. PH&S management also reserves the right to monitor e-mail and telephone usage. I understand that this Confidentiality and Nondisclosure Statement does not limit my right to use my own general knowledge and experience, whether or not gained while employed by PH&S, or my right to use information that becomes generally known to the public through no fault of my own. I understand that if I breach the terms of this Confidentiality and Nondisclosure Statement, PH&S may institute disciplinary action up to and including termination of my employment with Providence Health & Services. Signature of Employee: Date:

Note: The signature field above requires a handwritten signature. After the form is populated, please print and sign manually as needed.

The use of electronic signatures is currently under review by Enterprise Security and may replace manual signatures in the near future.

Employee ID

ACCEPTABLE USE AGREEMENT

This Acceptable Use Agreement applies to Providence Health & Services ( PH&S) employees, volunteers, trainees, and all others doing business with Providence.

Compliance with this agreement is a condition of continued employment or association with PH&S according to the Acceptable Use of Information Systems security policy found in the system policy manual.

The Acceptable Use of Information Systems policy describes the appropriate use of Providence information and technology resources including data, systems, networks and devices including but not limited to desktop computers, laptops, PDAs, fax machines and copiers and is intended to promote and protect the confidentiality, integrity, and availability of PH&S information and technology.

I am aware and agree, unless further described herein:

Internet usage, communications and transactions are not private. All computer activity is recorded and can be traced to a specific user ID.

Information and technology associated with or belonging to PH&S must be protected by taking appropriate mea-sures such as keeping passwords private, encrypting all computers and devices, and locking all portable devices. Additional information and online training on how to protect information and technology is provided by Provi-dence.

Information and technology is for business use and must not be used for purposes which may interfere or are in conflict with the PH&S mission and/or policies. Any use of PH&S information or technology for a purpose not specifically authorized by PH&S is prohibited.

PH&S reserves the right to limit or restrict the use of information or technology to meet the business and service obligations of the organization.

Although information and technology resources are for business use, limited personal use may be permitted with the following restrictions:

Usage must be reasonable, lawful and ethical and cannot be offensive or disrespectful to co-workers or others in the work or patient care environment.

Usage must not interfere or be in conflict with PH&S responsibilities or productivity.

IMPORTANT: In addition to termination, non-compliance could result in further action, including civil or criminal prosecution. Violation of these requirements by a third party contracted with PH&S may result in termination of the representative’s contractual arrangement with PH&S for default and may further result in such representative being subject to civil or criminal laws, as applicable.

By signing this document, I acknowledge that I have read, understand, and agree to abide by the Providence Health & Services Acceptable Use Agreement. This agreement does not limit my right to use my own general knowledge and experience, whether or not gained while employed by PH&S, or my right to use information which is known to the general public through no fault of my own.

Signature: ___________________________________ Date: ___/___/_____ Employee ID: __________________________

Printed Name: __________________________________________________ Position: _____________________________

Department: _________________________________ Work Location/Facility Site: ________________________________

This document is classified Providence Confidential. Do not redistribute without the approval of Enterprise SecurityCopyright © 2008, Providence Health & Services. All rights reserved.

Providence Code of Conduct /// Acceptable Use Agreement /// 1

 

            Direct Deposit          Authorization Form 

  Direct Deposit is a mandatory requirement of employment.  Please complete the following form and attach a voided check for each account.  If you have questions please call 1‐888‐687‐3753 or extension 20753.   

Authorizing Information 

Type of Account:  Bank Name:  

  Checking Account  Routing Number:   

   Savings Account   Account Number:  

         Select One:     Fixed Amount  $_______ 

       Fixed Percentage______% (100% goes if here if you want all of your paycheck in this one account)       Remainder 

Type of Account:  Bank Name:  

  Checking Account  Routing Number:   

   Savings Account   Account Number:  

       

  Select One:     Fixed Amount $_______ 

       Fixed Percentage______%   (100% goes if here if you want all of your paycheck in this one account)       Remainder 

TAPE VOIDED CHECK HERE IF AVAILABLE  (please do not staple) 

Authorization Signature 

I herby authorize Providence Health & Services to make payroll deposits to my bank account indicated on the attached VOIDED CHECK (deposit slip will only be accepted for a savings account).  The effective date for the direct deposit will be approximately one month from the receipt of this authorization.  

 You can update or change your direct deposit information via Employee Self Service (ESS) at anytime.   ______________________________________               ______________________________________         _________     Employee Name (please print)                                             Employee Signature                                                         Date 

01-Direct Deposit

Employee ID