* = Required Information
Name
*
Date
• Tour of office/Introduction of Agency personnel
Date Completed
Orientation by Whom
Personnel Initials
• Completion of all employment forms
Date Completed
Orientation by Whom
Personnel Initials
• Personnel File
Date Completed
Orientation by Whom
Personnel Initials
- Application
Date Completed
Orientation by Whom
Personnel Initials
- Signed job description
Date Completed
Orientation by Whom
Personnel Initials
- Professional license, certification, registration, and/or transcript, as appropriate
Date Completed
Orientation by Whom
Personnel Initials
- Physical exam and drug test, as appropriate
Date Completed
Orientation by Whom
Personnel Initials
- Standard Precautions orientation
Date Completed
Orientation by Whom
Personnel Initials
- Criminal Background Check (CJIS)
Date Completed
Orientation by Whom
Personnel Initials
• Name and Photo Identification and Copy of SSN card)
Date Completed
Orientation by Whom
Personnel Initials
• The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided:
Date Completed
Orientation by Whom
Personnel Initials
- Overview of agency mission
Date Completed
Orientation by Whom
Personnel Initials
- Organizational structure
Date Completed
Orientation by Whom
Personnel Initials
- Goals, philosophy, and objectives
Date Completed
Orientation by Whom
Personnel Initials
- Services/ Plan of Care provided by the agency
Date Completed
Orientation by Whom
Personnel Initials
- Contract agreement, if applicable
Date Completed
Orientation by Whom
Personnel Initials
- Medicare, Medicaid, and state license regulatory overview
Date Completed
Orientation by Whom
Personnel Initials
• Overview of functions and coordination with other services
Date Completed
Orientation by Whom
Personnel Initials
• Client Rights and Responsibilities
Date Completed
Orientation by Whom
Personnel Initials
• Infection prevention and control
Date Completed
Orientation by Whom
Personnel Initials
• Emergency Preparedness within agency and client’s home
Date Completed
Orientation by Whom
Personnel Initials
• Safety Plan and policies
Date Completed
Orientation by Whom
Personnel Initials
• Performance improvement expectations and plan
Date Completed
Orientation by Whom
Personnel Initials
_
• Agency personnel policies, including employee grievance procedures, safety management programs and individual employee responsibility
Date Completed
Orientation by Whom
Personnel Initials
_
• Confidentiality of client information (signed and dated confidentiality statement)
Date Completed
Orientation by Whom
Personnel Initials
_
• Cultural diversity and sensitivity
Date Completed
Orientation by Whom
Personnel Initials
_
• Ethical issues
Date Completed
Orientation by Whom
Personnel Initials
_
• Documentation and reporting guidelines
Date Completed
Orientation by Whom
Personnel Initials
_
- MAR ( Check list if applicable)
Date Completed
Orientation by Whom
Personnel Initials
_
- MAR ( Check list if applicable)
Date Completed
Orientation by Whom
Personnel Initials
_
- Incident Report
Date Completed
Orientation by Whom
Personnel Initials
_
- Complaint Log
Date Completed
Orientation by Whom
Personnel Initials
_
- Reportable Events
Date Completed
Orientation by Whom
Personnel Initials
_
• Competency Testing
Date Completed
Orientation by Whom
Personnel Initials
_
• Self Skill Assessment Checklist
Date Completed
Orientation by Whom
Personnel Initials
_
• Time sheet Recording
Date Completed
Orientation by Whom
Personnel Initials
_
• Pay Periods and due dates
Date Completed
Orientation by Whom
Personnel Initials
_
Employee Name
*
Date
Staff Name
*
Title
*
Submit