Onboarding Document

BACKGROUND AUTHENTICATION FORM

EMERGENCY CONTACT INFORMATION

We would like to have the names of two (2) contacts that we could call in the case of emergency. Please provide that information below for our files and reference.

The information contained in this application is correct to the best of my knowledge. I hereby authorize FIRST CONNECT CENTER LLC and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all Information, verbal or written, pertaining to me, to FIRST CONNECT CENTER LLC or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. And its designated agents and representatives shall maintain all information received from this authorization in a confidential manner. I hereby authorize the obtaining of a Consumer Report/Investigative Consumer Report at any time following receipt of this Authorization, and throughout the length of my employment with Company to the extent permitted by law until I withdraw my authorization in writing.

I acknowledge receipt of the BACKGROUND CHECK DISCLOSURE and A SUM- MARY OF YOUR RIGHTS UNDER THE FCRA (FAIR CREDIT REPORTING ACT).

Required current address and previous addresses to cover the 7 years of background-check

Date

Please upload your SSN:

DIRECT DEPOSIT AUTHORIZATION FORM

Account Information

Please attach a voided check for each bank account to which funds should be deposited.

I hereby authorize First Connect Center LLC to initiate automatic deposits to at the financial institution name above. the account listed above. This authorization will remain in effect until First Connect Center LLC receives a written notice of cancellation from me, or until I submit a new direct deposit form to the payroll Department.

EMPLOYEE HANDBOOK ACKNOWLEDGEMENT FORM

I acknowledge that I have received a copy of First Connect Handbook.

I understand that in processing my application with First Connect an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job-related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless First Connect from any liability. I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize First Connect to check my credit and conviction records, as needed, on a continuous basis as it relates to my employment. I am granting First Connect authorization to release confidential medical information upon the request from First Connect clients while I am actively working at the client’s facility and /or during the profiling and placement processes.

I understand that First Connect goal is to always provide me with a consistent level of service. If for any reason I am dissatisfied with First Connect or the service provided by one of First Connect Clients, I am encouraged to contact the local manager to discuss the issue. First Connect has processes in place to resolve customer complaints in an effective and efficient manner. If the resolution does not meet my expectation, I am encouraged to call the First Connect Corporate office at (866) 495-4770. A corporate representative will work with me to resolve my concern. I understand that any individual or organization that has a concern about the quality and safety of patient care delivered by First Connect healthcare professionals, which has not been addressed by First Connect management, is encouraged to contact the Joint Commission at www.jointcommission.org or by calling the Office of Quality Monitoring. First Connect demonstrates this commitment by taking no retaliatory or disciplinary action against employees when they do report safety or quality of care concerns to the Joint Commission.

I have read and understand First Connect policies and my requirements as a First Connect employee. I understand that if I have any questions and/or need clarification for items addressed in the handbook, it is my responsibility to contact the First Connect office to discuss.

HEPATITIS B DECLINATION

I had appropriate training regarding hepatitis B, hepatitis B Vaccination, the efficiency, Safety, method of administration and benefits of vaccination, given free of charge to the employee.

I understand that my occupational exposure to patients, blood or other potentially infectious materials at healthcare facilities with the following vaccine preventable diseases puts me at risk of acquiring the disease. I have had the opportunity to be vaccinated, however, I choose to decline the vaccination(s) checked below at this time. I understand that by declining vaccine protection I continue to be at risk of acquiring the disease.

This statement is not a waiver; employees can request and receive the hepatitis B vaccination at later date if they remain occupationally at risk for hepatitis B.

An employer cannot require:

• Employees to waive liability in order to receive the vaccine.

• Participation in pre-screening as a prerequisite for receiving the vaccine.

HIPAA CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT
EMPLOYEE DOCUMENTATION OF HIPAA TRAINING

This Agreement entered this day of 20 by and between First Connect Staffing, hereafter the "Healthcare Facility" and (Independent contractor), hereafter "Contractor", sets forth the terms and conditions under which Information created or received by or on behalf of this Healthcare Facility (hereafter collectively referred to as protected health Information or "PHI") may be used or disclosed under state law and the Health Insurance Portability and Accountability Act of 1996 and updated through HIPAA Omnibus Rule of 2013 and will also uphold regulations enacted there under (hereafter "HIPAA").

THEREFORE, In consideration of the premises and the covenants and agreements contained herein, the parties hereto, Intending to be legally bound hereby, covenant and agree as follows:

1. All parties acknowledge that meaningful employment may or will necessitate disclosure of confidential information by this Healthcare Facility to the Employee and use of confidential Information by the Employee. Confidential information includes, but is not limited to, PHI, any information about patients or other employees, any computer log-on codes or passwords, any patient records or billing information, any patient lists, any financial information about this Healthcare Facility or its patients that is not public, any intellectual property rights of Practice, any proprietary Information of Practice and any information that concerns this Healthcare Facility's contractual relationships, relates to this Healthcare Facility's competitive advantages, or is otherwise designated as confidential by this Healthcare Facility.

2. Disclosure and use of confidential information Includes oral communications as well as display or distribution of tangible physical documentation, in whole or in part, from any source or in any format (e.g., paper, digital, electronic, Internet, social networks like Facebook™ or MySpace™ posting, magnetic or optical media, film, etc.). The parties have entered Into this Agreement to induce use and disclosure of confidential Information and are relying on the covenants contained herein in making any such use or disclosure. This Healthcare Facility, not the Employee, is the records owner under state law and the Employee has no right or ownership interest in any confidential information.

3. Confidential Information will not be used or disclosed by the Employee in violation of applicable law, including but not limited to HIPAA Federal and State records owner statute; this agreement; the Practice's Notice of Privacy Practices, as amended; or other limitations as put in place by Practice from time to time. The intent of this Agreement is to ensure that the Employee will use and access only the minimum amount of confidential Information necessary to perform the Employee's duties and will not disclose Confidential Information outside this Healthcare Facility unless expressly authorized in writing to do so by this Healthcare Facility. All Confidential information received (or which may be received in the future) by Employee will be held and treated by him or her as confidential and will not be disclosed in any manner whatsoever, in whole or in part, except as authorized by this Healthcare Facility and will not be used other than in connection with the employment relationship.

4. The Employee understands that he or she will be assigned a log-on code or password by Practice, which may be changed as this Healthcare Facility, in its sole discretion, sees fit. The Employee will not change the log-on code or password without this Healthcare Facility's permission. Nor will the Employee leave confidential information unattended (e.g., so that it remains visible on computer screens after the Employee's use). The Employee agrees that his or her log-on code or password is equivalent to a legally- binding signature and will not be disclosed to or used by anyone other than the Employee. Nor will the Employee use or even attempt to learn another person's log-on code or password. The Employee Immediately will notify this Healthcare Facility's HIPAA Privacy Officer upon suspecting that his or her log- on code or password no longer is confidential. The Employee agrees that all computer systems are the exclusive property of Practice and will not be used by the Employee for any purpose unrelated to his or her employment. The Employee acknowledges that he or she has no right of privacy when using this Healthcare Facility's computer systems and that his or her computer use periodically will be monitored by this Healthcare Facility to ensure compliance with this Agreement and applicable law.

5. Immediately upon request by this Healthcare Facility, the Employee will return all confidential Information to this Healthcare Facility and will not retain any copies of any confidential information, except as otherwise expressly permitted in wring signed by this Healthcare Facility. All confidential Information, including copies thereof, will remain and be the exclusive property of this Healthcare Facility, unless otherwise required by applicable law. The Employee specifically agrees that he or she will not and will not allow anyone working on their behalf or affiliated with the Employee in any way, use any or all the confidential information for any purpose other than as expressly allowed by this Agreement. The Employee understands that violating the terms of this Agreement may, in this Healthcare Facility's sole discretion, result in disciplinary action including termination of employment and/or legal action to prevent or recover damages for breach. Breach reporting is imperative.

6. The parties agree that any breach of any of the covenants or agreements set forth herein by the Employee will result in irreparable injury to this Healthcare Facility for which money damages are inadequate; therefore, in the event of a breach or an anticipatory breach, Practice will be entitled (In addition to any other rights and remedies which it may have at law or in equity, including money damages) to have an injunction without bond Issued enjoining and restraining the Employee and/or any other person involved from breaching this Agreement.

7. This Agreement shall be binding upon and endure to the benefit of all parties hereto and to each of their successors, assigns, officers, agents, employees, shareholders and directors. This Agreement commences on the date set forth above and the terms of this Agreement shall survive any termination, cancellation, expiration or other conclusion of this Agreement unless the parties otherwise expressly agree in writing.

8. The parties agree that the Interpretation, legal effect and enforcement of this Agreement shall be governed by the laws of the State and by execution hereof, each party agrees to the jurisdiction of the courts of the State. The parties agree that any suit arising out of or relation to this Agreement shall be brought in the county where this Healthcare Facility's principal place of business is located.

IN WITNESS WHEREOF, and Intending to be legally bound, the parties hereto have executed this Agreement on the date first above written, when signing below and after training on HIPAA Law with full understanding this agreement shall stand.

EMPLOYEE DOCUMENTATION OF HIPAA PRIVACY TRAINING

The Health Insurance Portability Act of 1996 (HIPAA) requires our privacy officer to train employees on our health Information privacy policies and procedures to the HIPAA Omnibus Standards of 2013 which also includes HI-TECH and Protected Health Information (PHI), Electronic Protected Health Information (ePHI) and Electronic Health Records (EHR). All employees with treatment, payment or healthcare operations responsibilities, which allow access to protected health information, are trained with updates periodically as State and Federal mandates require. HIPAA also requires that we keep this documentation (that the training was completed) for six years after the training. I, the undersigned do hereby certify that I have received, read, understood and agree to abide by this Healthcare Facilities HIPAA Policies and Operating Procedures.

Employee Printed Name:

2024-2025 INFLUENZA VACCINE DECLINATION FORM

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills thousands in the United States each year.

• Influenza vaccination is recommended for me and all other healthcare personnel to protect this.

• Facility’s patients from influenza, its complications, and death.

• If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.

• If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existent.

• I understand that the strains of virus that cause influenza infection change almost every year and even if they don’t, my immunity declines over time. This is why vaccination against influenza is recommended each year.

• I understand that I cannot get influenza from the influenza vaccine.

• The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including all patients in this.

• Healthcare facility, coworkers, my family and my community prevention of and reduction in the severity of influenza illness and reduction of outpatient visits, hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviatestress on the U.S. health care system.

• Influenza vaccination is especially important during the SARS-CoV-2 pandemic.

I am choosing to decline flu vaccine for the one of the following reasons. Please check all that apply.

Medical Precaution or ContraindicationReligious BeliefPersonal BeliefOther ReasonPrefer not to answer

I acknowledge that I am required to follow non-pharmaceutical interventions (e.g. masking, screening) asdirected by Chief Clinical Officer, the local vaccine authority and that my manager, including division and departmental leadership will be notified of the same.

I acknowledge, if I later decide to become vaccinated, that I may receive the vaccine through UCSF OccupationalHealth Services, or off-site and provide documentation to UCSF Occupational Health Services.

I have read and fully understand the information on this declination form. Knowing these facts, I DO NOT want the vaccination as recommended and choose to decline a vaccination at this time.

OSHA EMPLOYEE ACKNOWLEDGEMENT OF RECEIPT OF TRAINING

New Hire Date:
It is policy that the first consideration of work shall be the protection of the safety and health ofall employees. A Hazard Communication Plan has been developed to ensure that all employees receive adequate information about the possible hazards that may result from the various materials used in our operations. This Hazard Communication Plan will be monitored by the Safety Program Administrator (SPA) who will be responsible for ensuring that all facets of the program are carried out, and that the program is effective.

OSHA requires that all employers provide employees with effective information and training onhazardous chemicals in their work area at the time of their initial assignment, and whenever a new chemical hazard the employees have not previously been trained about is introduced into their work area.
Due to this federal requirement, the Town provides such training as part of new employee orientation and we require that each new employee acknowledge receiving this training bycompleting the following:

I Acknowledge receipt of training on the Hazard Communication Standard (29 CFR 1910.1200). Specifically, I have been instructed on the hazardous chemicals present in the workplace, and Iunderstand the importance of protecting myself and my fellow workers from exposure to the various hazardous chemicals. I have been instructed and understand how to read and evaluatelabels and Safety Data Sheets and promise to do my part to make our organization a safe working environment.
I further understand that it is my responsibility to immediately inform my supervisor, manager,and/or department safety committee representative of any hazardous chemicals that I am not familiar with or do not know how to handle safely. In addition, it is my responsibility to immediately inform them whenever I observe a fellow employee handling a chemical in an unsafe manner.
Finally, I will do my part to insure that proper labels are maintained on all secondary containers that I utilize during the course of my work.

Date

CONFIRMATION LETTER FOR PROJECT ACCEPTANCE

It is my pleasure to inform you that, I,

I accept the offer Made by through First Connect Center

I consider the sensitivity of the issue, I accept this opportunity and I will start as soon as my past employment and education, criminal records, motor vehicle records, personal references, and other job-related data provided on this application will be verified and completed by First Connect Center LLC.

TB SCREENING QUESTIONNAIRE

TB RISK FACTORS AND MEDICAL CONDITIONS:

Date