FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH FORMS …fourcorners.ws/documents/personnel_forms.pdf ·...

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH FORMS

TABLE OF CONTENTS

PERSONNEL

Acknowledgement or Property / Keys Held by Employee

Authorization for Medical Treatment

Corporate Compliance Plan

Conflict of Interest / Related Party Declaration Form

Credentialing Packet

Employed Practitioners Application for Clinical Privileges

Employed Provider Annual Re‐credentialing

Driving Information Form

Policy on Controlled Substances and Alcohol

Drug and Alcohol Screening

Observed Behavior – Reasonable Suspicion Record

Drug Testing Sites

Emergency Contact Information

Disciplinary Action

Employee Data Record

Employee Handbook Receipt and Acknowledgement

2.18 Information Technology Use Policy

Equipment Use and Return Assurance

Fire Drill Documentation

Health Insurance Acknowledgement

Individual Supervision Log

Leave Request

Application for Leave Bank Time

Leave Bank Donation Request

Leave Bank Medical Verification

Request for Increased Compensation at Licensure

New Employee Orientation Checklist

Performance Management One up Reviewer Guidelines

Other Trained Staff Certification – Tracker

Non‐Exempt Employees Overtime Pre‐authorization

2.27 Sexual Harassment Prevention

Supervision Tracking Form

Supervision Hiring Checklist

3.15 Telecommunications

Training Authorization

Work Time Variance Request

All resources provided to carry out the responsibilities of an employee’s job are the property of FCCBH, Inc. This includes any item that is portable in nature and that may be used on or off a FCCBH premises. A Property Held by Employees form must be filled out for the following: all keys to FCCBH, Inc. facilities, vehicles or other, laptop computers, all computer accessories, Palm Pilots and all PDA accessories and instruction manuals, hardware or software used off site, compact disks and floppy disks purchased by FCCBH, Inc., cellular phones and accessories including leather covers and auto chargers, books or any other item belonging to FCCBH.

DATE: __________________________________________________________________________ EMPLOYEE: ____________________________________________________________________ Date Item Description (Include manufacturer, model, serial # Received date of purchase and other identifiers , for keys include Date Returned what doors in what facility) Business office must initial receipt

_____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ _____ __________________________________________________ _____ I hereby acknowledge that upon severance from FCCBH, Inc. I will return all FCCBH, Inc. property assigned for my use to the Associate Director for Administrative Services or his / her designee on my last working day. Upon termination I will return all FCCBH, Inc. property immediately. I also acknowledge that I am responsible to safeguard all property from damage or loss and that I am liable for loss or damage. I agree to compensate FCCBH, Inc. for lost or damaged property at replacement value. I agree that the cost of lost or damaged property shall be deducted from my final paycheck. ________________________________________ ________________ Employee Date Comments: _______________________________________________________________________ __________________________________________________________________________________ Original to Personnel Office ________ Copy to Supervisor _________ 8/2003

Four Corners Community Behavioral Health Acknowledgement of Property/ Keys Held by Employee

4/2003

Price Office P.O. Box 867; 575 E. 100 S. Price, UT 84501 Telephone (435) 637-2358 FAX (435) 637-9141

Castle Dale Office P.O. Box 387; 45E. 100 S. Castle Dale, UT 84513 Telephone (435) 381-2342 FAX (435) 381-2542

Moab Office 198 East Center St. Moab, UT 84532 Telephone (435) 259-6131 FAX (435) 259-5369

Administrative Plaza P.O. Box 867; 105 W 100 N., #2 Price, UT 84501 Telephone (435) 637-7200 FAX (435) 637-2377 www.fourcorners.ws

FCCBH Inc’s Corporate Compliance Plan

Four Corners Community Behavioral Health Center wants to create a value-based organizational culture built on continuing quality improvements and high ethical standards. A corporate compliance program is required by both state and federal authorities. Our State Medicaid Contract specifically requires that our Center have a corporate compliance program to prevent Fraud, Waste and/or Abuse within the organization. We have an obligation to investigate Fraud, Waste, and Abuse issues if they come up.

Fraud-any intentional deception that violates Federal/ State criminal or civil law. This includes but isn’t limited to; theft, acceptance of bribes or gratuities, making false statements, misrepresentation of material facts, accepting kickbacks. Waste- extravagant, careless needless expenditure of public funds caused by deficit policies, procedures, system controls, decisions or programs. Abuse- is the intentional wrongful or needless expenditure of funds that causes loss or misuse of center resources. It also includes physical, sexual or other inappropriate mistreatment of clients.

Reporting Compliance Issues All employees, contractors, members of the public etc. are encouraged to discuss operational and compliance issues first with the service supervisor where compliance questions may occur. However, anyone within or outside the organization can contact the Compliance Officer directly with questions or concerns. All reports will be investigated unless inadequate information is provided. Anyone reporting a compliance issue will be protected from retaliation or harassment to the fullest extent possible. Complainant confidentiality will be protected unless their identity must be disclosed according to law, regulation, or policy. _______________________________________________________________________________

Certification Concerning Fraud and Abuse Check One:

I hereby certify that I have reported to my supervisor any fraud, waste or abuse committed in the

past 12 months by any employee or other person connected with FCCBH, Inc. about which I have

any knowledge:

Such reports are (list all)

o ___________________________________________________________

o ___________________________________________________________

Or

I hereby certify that I have no knowledge, nor have I witnessed any fraud, waste or abuse

committed by any employee or other person otherwise connected with FCCBH, Inc. during the

past 12 months.

________________________________________________ _________________ Employee Signature Date

Compliance Officer Karen Dolan [email protected]

105 West 100 North 1-435-637-7200 ex 1314 2/2009

Four Corners Community Behavioral Health, Inc. Conflict of Interest / Related Party Declaration Form

Employee Name

Date

Position Supervisor

This declaration is for related party disclosures as described:

Employees are prohibited from using their positions in a manner that is or gives the appearance of being motivated by a desire for private gain for themselves or others, particularly those with whom they have family, business, or other ties. FCCBH, Inc. employees are required to disclose any family members, personal business connections with or ties to other FCCBH, Inc. employees, vendors, contractors or business associates.

I have no related party disclosures as described above. I have the following related party disclosures and I confirm that I have not used my position for personal gain as described above. (Attach additional pages as needed.)

This declaration is for disclosure of outside activities that may constitute a general conflict of interest as described:

No employee shall accept or participate in employment, volunteer responsibilities, or interest in a business, which results in a conflict of interest as described in the FCCBH Policies 2.06 PERSONNEL, Conflict of Interest and the Utah Public Employees Ethics Act (Title 67, Chapter 16 of the Utah Code). All employees involved in outside paid and / or volunteer activities shall disclose such activities so that potential conflict of interest can be understood, approved or disapproved to reduce or eliminate conflicts.

I have no activities outside of my employment with FCCBH, Inc. that may constitute a conflict of interest.

I have one or more activities outside of my employment with FCCBH, Inc. that may constitute a conflict of interest. I request a review and a determination of approval or disapproval. (Request is attached)

Employee Signature

Date

Supervisor Signature

Date

Supervisor Recommendations / Comments (Use other side if necessary) Executive Director Action

Outside Activity Approved Outside Activity Approval Denied Conditional Approval with these terms:

Executive Director Signature

Date

Revised 11-6-2003 8-22-01

AdministrativeOffice

105 West 100 North Price, UT 84501

Dear Professional Staff, Please complete and return the enclosed credentialing packet to the Human Resources office as quickly as possible but, no later than 30 days from the date you receive this letter. Medicaid has established more stringent requirements for healthcare providers to evidence that all clinicians are credentialed, re-credentialed and not debarred or otherwise sanctioned. FCCBH, Inc. needs comprehensive information on file and a system to track credentialing and re-credentialing. The information you provide will be used to verify your education, experience, and competence to perform each Clinical Privilege you request as a part of your job assignment. The packet contains the following forms:

1. Application for Clinical Privileges 2. Statement of Attestation

We also need copies of current licenses/certificates, diplomas and/or transcripts and your resume. You will be contacted if you do not provide any of these documents. Please help us process your application for clinical privileges expeditiously. If you have any questions or need assistance, please contact me. Your time and effort in completing these documents is greatly appreciated. Sincerely, Karen Dolan LCSWAdministrator Enclosure

Employed Practitioner Credentialing and Re-Credentialing 11/28/2006 Page 2 of 8

Administrative Office


Employed Practitioners Application for Clinical Privileges

Check all that apply

[ ] Social Workers (LCSW, CSW or SSW) ● Licensed to practice in the state of Utah [ ] Substance Abuse Counselor (LSAC, SAC)

● Licensed to practice in the state of Utah [ ] Licensed Professional Counselor (LPC, PC Intern) ● Licensed to practice in the state of Utah [ ] Marriage and Family Therapist (MFT, MHT-Externship, MHT-Internship)

● Licensed to practice in the state of Utah [ ] Psychologist (Ph.D. or Psychology Resident)

● Licensed to practice in the state of Utah

[ ] Physician and Surgeon, Controlled Substance, Osteopathic Physician (MD, Intern, Resident) ● Licensed to practice in the state of Utah

[ ] Physician’s Assistant (PA)

● Licensed to practice in the state of Utah [ ] Registered Nurse (RN, APRN, LPN) ● Licensed to practice in the state of Utah

Application reviewed by Compliance officer Date ____________________ Signature ________________

[ ] Certified Clinical Supervisor (CCS) ● Credentialed to practice in the state of Utah




Answer all questions or put NA if not applicable PERSONAL DATA: Name ________________________________________________________________________________________ Last First Middle Home Address: ________________________________________________________________________________ Street City State ZIP

Home Phone:

Place of Birth:

Date of Birth:

Citizenship:

Social Security #:

Tax ID#:

Medicare # (circle one) Yes No

NPI #:

EDUCATIONAL INFORMATION: (Required for verification purposes) Undergraduate Specialty: _________________________________________________________________ Facility Name: ________________________________________________________________________________ City and State: ________________________________________________________________________________ Enrolled From: ______________ To: ______________Completed: ___Yes ___ No If No, please explain: _____________________________________________________________________________________________ Graduate/Medical School Specialty: ___________________________________________________________ Facility Name: ________________________________________________________________________________ City and State: ________________________________________________________________________________ Enrolled From: ______________ To: ______________Completed: ___Yes ___ No If No, please explain: _____________________________________________________________________________________________ Residency (If applicable) Specialty: ________________________________________________________________ Facility Name: _________________________________________________________________________________ City and State: _________________________________________________________________________________ Dates of Residency – From: ___________ To: __________Completed: ___Yes ___ No If No, please explain: _____________________________________________________________________________________________




If you are a foreign medical school graduate, are you certified by the Educational Commission for Foreign Medical

Graduate (ECFMG)? ___Yes ___ No ECFMG #: ____________________ Issue Date: __________________

DEA/CDS CERTIFICATES: List your current DEA Certificate and Controlled Dangerous Substances registration information, if applicable. Be sure to include a copy of your current certificates when you return your application materials. ____________________________ ______________ _________________________ _________ _______________ DEA Certificate # Exp. Date CDS Registration # State Exp. Date BOARD CERTIFICATIONS/SPECIALTY: List below any certifications you have received from any nationally recognized specialty boards. Principle Specialty: _________________________ Name of Board if Board Certified: _______________________

Exam Information (check one) ___ Oral Taken ___ Oral Scheduled ___Written Taken ___Written Scheduled ___No

plans to take exam Date of Exam: ______________ Date Certified: _______________ Re-exam Date: ___________

PROFESSIONAL LICENSES: Indicate original licensure date through current expiration date for each state in which you are or have been licensed / certified in the past (10) years. Include an explanation for any license / certification not current or active. Licensing Board State Specialty Active

Or Non-Active Certificate # Original

Issue Date Expiration Date

How many years do you have of post-license clinical experience in the direct provision of mental health/substance

abuse care? _______ Years of managed care experience? _______

INSURANCE INFORMATION: List below the names and complete addresses of any malpractice carrier (s) (excluding coverage through FCCBH, Inc.), who has provided coverage for you in the past five years.

_____________________________________________________________________________________________

Carrier (Name and Complete Address)

____________________________________ __________________________________________________

Dates of Coverage Reason for Changing




PRIMARY AGENCY/ EMPLOYER INFORMATION Current Provider Agency/Employer Name: Four Corners Community Behavioral Health, Inc. Address: Business Office, 105 West 100 North, Price, UT 84501; Phone (435) 637-7200, Fax (435) 637-2377 OTHER AGENCY/EMPLOYER INFORMATION (CURRENT) Provider Agency/Employer Name: _________________________________________________________________ Address: __________________________________________ Phone: ________________ Fax:_________________ WORK HISTORY Please list previous employment in your professional field of practice for the last five years. Agency/Employer: ____________________________________ Position: _________________________________ Contact Name/Title: ____________________________________ City and State ____________________________ Reasons for leaving: ____________________________________________________________________________ Agency/Employer: ____________________________________ Position: _________________________________ Contact Name/Title: ____________________________________ City and State ____________________________ Reasons for leaving: ____________________________________________________________________________




PROVIDER PROFILE (If “Yes” is checked, please explain fully on a separate sheet) 1. Health Status: Do you currently have any physical, mental, or emotional conditions which may impair your ability to

render professional services which are the subject of this application? ___Yes ___ No Do you currently use illegal drugs or abuse drugs and/or alcohol? ___Yes ___ No 2. Insurance Coverage: Has your professional liability insurance coverage ever been denied, cancelled, or non-renewed or

initially refused upon applications? ___Yes ___ No 3. License: Has your medical and/or professional license in any state ever been revoked, suspended, placed on probation,

conditional status, or limited? ___Yes ___ No Have you ever voluntarily surrendered your license? ___Yes ___ No Are formal charges pending against you at this time? ___Yes ___ No

4. DEA: Has your DEA registration Certificate ever been suspended, revoked, subjected to probation, placed on conditional

status, or limited? ___Yes ___ No 5. Hospital Privileges: Has any hospital ever dismissed you from its staff, revoked, suspended or limited privileges or taken

formal action against you? ___Yes ___ No 6. Hospital Sanctions: Have you ever surrendered your clinical privileges upon threat of censure, restriction, suspension or

revocation of such privileges? ___Yes ___ No 7. Professional Membership(s): Has your membership in any professional society or association ever been canceled, revoked,

or censured? ___Yes ___ No 8. Medicare/ Medicaid: Have you ever been fined, had an arrangement suspended, been expelled from participation or had

criminal charges brought against you by Medicare or Medicaid? ___Yes ___ No 9. Criminal Offenses: Have you ever been convicted of a felony or involved in charges relating to moral or ethical turpitude ?

___Yes ___ No Have you ever been named as a defendant in any criminal proceeding? ___Yes ___ No 10. Board Discipline: Have you ever been the subject of disciplinary proceedings by any professional association or

organization (i.e., state licensing board; county, state or national professional society; hospital medical or clinical staff)? ___Yes ___ No

11. Malpractice Action: Has any malpractice action against you been brought or settled in the past five years or has there been any unfavorable judgment against you in a malpractice action? ___Yes ___ No

To your knowledge, is any malpractice action against you currently pending? ___Yes ___ No Note: Documentation is required if you have any malpractice claims pending or settled in the past (5) years (include any

settlements/adjudication’s, original complaint and final disposition.) Malpractice Claim Information Form If the answer to any of the questions above was “yes”, please complete the Malpractice Claim Information Form on page 7 for each claim. Make additional copies for each claim.




CONFIDENTIAL MALPRACTICE CLAIM INFORMATION

Patient’s Name: ____________________________________________Date of Occurrence: ___________________ Allegations: ___________________________________________________________________________________ _____________________________________________________________________________________________ Date Claim Filed: ___________________ Date of Settlement: ________________ Amt. of Settlement: __________ Status of Claim: ___ Pending ___ Settled / Case Settled: ___In Court ___Out of Court ___With Prejudice ___Without Prejudice Description of the Incident: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What actions/policies have been put in place to prevent this from happening? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




ATTESTATION PARTICIPATION STATEMENT

I certify that all information provided to Four Corners Community Behavioral Health, Inc. is true and correct to the best of my knowledge and belief. I agree to notify Four Corners Community Behavioral Health, Inc. promptly if there are any material changes in the information provided, whether prior to or after my acceptance as a Four Corners Community Behavioral Health, Inc. participating provider. I understand and agree that if Four Corners Community Behavioral Health, Inc. discovers that my application contains any significant misstatement, misrepresentations, or omissions, Four Corners Community Behavioral Health, Inc. may void, in its sole discretion this application and any related participating provider agreements. I authorize Four Corners Community Behavioral Health, Inc. credentialing staff to consult with the National Practitioner Data Bank, State Licensing Board(s), educational institutions, specialty boards, malpractice insurance carriers, Educational Commission for Foreign Medical Graduates, hospitals, professional references and any other person or entity from whom/which information may be needed to complete the credentialing process or to obtain and verify information concerning my membership, professional competence, character and moral and ethical qualifications and I also authorize all of them to release such information to Four Corners Community Behavioral Health, Inc. I release Four Corners Community Behavioral Health, Inc. and its employees and agents and all those whom Four Corners Community Behavioral Health, Inc. contacts from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application. I understand that Four Corners Community Behavioral Health, Inc. is required by the State of Utah to perform a criminal records check as a condition for participation. I also understand that I have the right to challenge the accuracy and completeness of any information contained in such a report. I consent to the release by any person to Four Corners Community Behavioral Health, Inc. of all information that may be relevant to an evaluation of my professional competency, character and moral and ethical qualifications, including any information relating to any disciplinary action or suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so. I further understand and agree that: (a) I am responsible for producing all information required or requested by Four Corners Community Behavioral

Health, Inc. in connection with this application; (b) Four Corners Community Behavioral Health, Inc. shall not consider credentialing verified before this

application is processed by the credentialing official. In the event that Four Corners Community Behavioral Health, Inc. decides not to accept me as a participating provider or to terminate my employment based on information in this application and I desire to have the decision reviewed, I will appeal such determination to Four Corners Community Behavioral Health, Inc. Executive Director and/or Board of Trustees. By signing this Attestation / Participation Statement I am not precluded from pursuit of any separate rights that I may have State or Federal Laws. ______________________________ ___________________________________ _________________ Name of Applicant (Please Print) Signature of Applicant Date

Four Corners Community Behavioral Health Driving Information Form

Date: _____________________ Name: __________________________________ Birth Date: ___________________ State: _______________________ Number: _________________________________ Completion of Defensive Drivers Course _______NO ______Yes Date Completed: ________________________________ Other drivers courses completed: Please fill out a new form when you have a change in your driving information. Please provide a copy of your DRIVERS LICENSE and any certificate of course completion. 7/2002

ACKNOWLEDGMENT OF HAVING READ AND UNDERSTANDING THE FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH

POLICY ON CONTROLLED SUBSTANCES AND ALCOHOL I, the undersigned employee or prospective employee of Four Corners Community Behavioral Health, hereby acknowledge that I have read the drug and alcohol policy of Four Corners Community Behavioral Health, and I understand it. I also agree to comply with the drug and alcohol policy as a condition of employment with Four Corners Community Behavioral Health. Further, I also understand that this agreement does not create an obligation or contract of employment between Four Corners Community Behavioral Health and myself. I also further consent to any request under the Policy for a urine or breath specimen for the purposes of detecting the presence of drugs, including the presence of such drugs as a metabolite, or alcohol and authorize its designated third-party administrator to collect the specimen. I also understand and consent to the test result being given to a Medical Review Officer (MRO), an authorized agent of Four Corners, and/or a third-party administrator. Further, I understand that appropriate action may be taken in conformity with the drug and alcohol policy, if the test result is positive. Name (Please Print) _________________________________________ Signature _________________________________________ Social Security Number _________________________________________ Date _________________________________________ Supervisor's Signature _________________________________________ 12/2001

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH

CONSENT FOR PRE-EMPLOYMENT DRUG AND ALCOHOL SCREENING

I, the undersigned in accordance with Four Corners Community Behavioral Health drug and alcohol-free workplace policy, acknowledge that I have read the policy and I understand it. I also understand that as a condition of being offered a position with Four Corners Community Behavioral Health, I will have to take and pass a drug test. If a position is offered with Four Corners Community Behavioral Health, I understand that I will have to comply with its terms for employment. I submit voluntarily to the Four Corners’ request for a specimen for the purpose of detecting drugs or alcohol or other Controlled Substances and authorize Four Corners Community Behavioral Health to have its third-party administrator collect the specimen for the purpose of the test. Further, I understand that those tests may be given to a Medical Review Officer and/or Four Corners Community Behavioral Health for review. I understand that failure to submit to providing a specimen, or if the sample reveals the presence of non-prescribed drugs, or other Controlled Substances, including their presence as a metabolite, it will preclude me from being offered a position with Four Corners Community Behavioral Health. I have read this form in full and understand the above statements. Name (Please Print) ___________________________________ Signature ___________________________________ Social Security Number ___________________________________ Date ___________________________________ Witness ___________________________________ 12/2001

Four Corners Community Behavioral Health Observed Behavior -Reasonable Suspicion Record

________________________________ _______________________________ _____________________ Employee Name Social Security Number Date of Birth _________________________________________ From: a.m./p.m. To: a.m./p.m. _________________________ Location Observation Time Observation Date Reasonable suspicion of current use or impairment by: Alcohol Drugs Both

Cause for Suspicion Appearance

Normal Flushed Puncture Marks Disheveled Bloodshot Eyes Tremors Dilated/Constricted Pupils Profuse Sweating Dry-mouth Runny Nose/Sores/Frequent Sniffing Inappropriate Wearing of Sunglasses Other: ________________________________________________________

Behavior: Speech

Normal Incoherent Slurred Silent Confused Slowed Whispering Loud Other: ________________________________________________________

Behavior: Awareness

Normal Confused Mood Swing Euphoria Lethargic Disoriented Lack of Coordination Aggressive/ Violent Paranoid Other: ________________________

Motor Skills: Balance

Normal Swaying Falling Staggering Head Bobbing Other: ______________________________________________________________________

Motor Skills: Walking and Turning

Normal Swaying Arms Raised for Balance Stumbling Falling Reaching for Support Other: ________________________________________________________________

Motor Skills: Other

Dropping Things Lack of Coordination Slowed Reaction Time Other Observable Actions of Behavior (Specify): ______________________________________________________ Check if the following conditions are met, (test only if both conditions are met):

Observations are specific, contemporaneous, and articulable on the appearance, behavior, speech, or body odors of the individual.

For alcohol testing, observations are made during, just preceding, or just after the individual is required to be in compliance (performing safety-sensitive functions) with DOT/FHWA regulations.

If unable to test in 2 hours of reasonable suspicion determination, state reasons: _______________________________ ________________________________________________________________________________________________ If unable to test within 8 hours of reasonable suspicion determination, cease attempts to test and state reasons: ________________________________________________________________________________________________ __________________________________ _________________________________ ________________ Supervisor / Official’s Name Signature Date Comments and/or corroboration by a second supervisor or official: ________________________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________ ____________________________________ ________________ Supervisor / Official’s Name Signature Date 12/2001

Four Corners Community Behavioral Health DRUG TESTING SITES

Price Area: Emery County Area: SOS Staffing Services Emery Medical Center 706 W. Price River Dr. 90 W. Main Price, UT Castle Dale, UT (Located by Wendy’s and Albertson’s) 435-381-2305 435-637-7210 Lab hours are Monday – Friday Open Monday – Friday, 8 am – 5 pm 8 am – 5 pm After hours page: Kris or Tauna @ 1-800-912-5995 or 1-800-912-5996 Moab Area: Green River Area: Allen Memorial Hospital Green River Medical Ctr. 719 W. 400 N. 305 W. Main Moab, UT Green River, UT 435-259-7191 435-564-3434 Lab hours are Monday – Friday 7 am – 5 pm Monday, Tuesday, Friday,

9 am – 5 pm Wednesday, 10 am – 6:30 pm Thursday, 9 am – 1:30 pm Must make appointment No drug testing after hours Salt Lake Area: Orem Area: Work Care Work Care 1751 W. Alexander St. (2410 So.) 190 W. 800 N. Suite 105 Orem, UT SLC, UT 801-224-4211 801-975-7913 Mon-Friday, 7:30 am – 5:30 pm 800-832-1998 After hours, cell phone Monday – Friday, 7:30 am – 9:00 pm 801-319-5561 They will do on-call drug tests for after hours, just call one of the above numbers and the answering machine will give you the details.

12/2003

EMERGENCY CONTACT INFORMATION Employee Name:________________________________________________________________ In case of emergency notify:

1) Name_______________________________________Relationship__________________ Address_________________________________________________________________ City______________________________ State___________ Zip Code_______________ Daytime Phone # _____________________Evening Phone #______________________

2) Name_______________________________________Relationship__________________ Address_________________________________________________________________ City______________________________ State___________ Zip Code_______________ Daytime Phone # _____________________Evening Phone #______________________

Any information you would like to volunteer that may be helpful in case of an emergency

Four Corners Community Behavioral Health, Inc.

DISCIPLINARY ACTION

This disciplinary action is to be considered a: Verbal warning __________ Written warning ____________

Employee name: _____________________________________ Date: ____________________ The following incident(s) have occurred constituting the need for a corrective action plan: The following is the Corrective Action Plan: I understand the problem and the Corrective Action Plan. I understand that failure to comply with the Corrective Action Plan could result in termination of my employment. Employee Signature: ___________________________________________________________ Supervisor Signature: ___________________________________________________________ Date: _____________________________________________

Four Corners Community Behavioral Health EMPLOYEE DATA RECORD

Four Corners Community Behavioral Health, Inc. is required to report the numbers of people who are employed by its corporation by ethnic group, sex, mental health license, other languages and degree. Your cooperation will be appreciated in completing the following information. This information will be used for reporting purposes only and will not be used in making an employment decision. Date ____________________________________________ Name _____________________________________________ Phone # ______________________ Address _________________________________________________________________________ City ________________________________ State ______________________ Zip _____________ Social Security Number ____________________________________________________________ Other Languages __________________________________________________________________ Employment Position ______________________________________________________________ Treatment Specialty _______________________________________________________________ Degree/Certificate _________________________________________________________________ Mental Health License(s) ___________________________________________________________ State(s) Licensed in ________________________________________________________________ ________________________________________________________________________________ VOLUNTARY SELF-IDENTIFICATION Sex Male ________ Female ________ Ethnic Group Native American ________ Pacific Islander ________ Black ________ White ________ Asian ________ Hispanic ________ Other _________________________________ 4/2004

E

I hereby acknowledge that I have reSeptember 2003. I have been advisrealize that management will clarify

I also understand that the statementsinformation concerning Four Corneprocedures and practices of employmof action against FCCBH, Inc. I uncreate, nor shall be construed as creindefinite term

I further understand that from time tsupplement the information containbasis as maintained at my work site

The employment arrangement betwEither the employee or employer caof Trustees has established this “at w This form covers the entire agreemeunderstandings that it does not cove I have read the “Employee Handbooacknowledge that the statements inc ________________________________Employee ________________________________Supervisor

___________________________Executive Director

Four Corners Community Behavioral Health, Inc.

MPLOYEE HANDBOOK RECEIPT ANDACKNOWLEDGEMENT

ceived, read and understand the policies in the Employee Handbook dated ed to read the entire handbook and have been allowed to ask questions and the covered material, should I require it, on request.

contained in the Employee Handbook are intended to serve as general rs Community Behavioral Health (FCCBH, Inc.) and its existing policies,

ent and not to create any contractual rights or serve as the basis for any cause derstand that nothing contained in the Employee Handbook is intended to ating an expressed or implied guarantee of employment for a definite or

o time, FCCBH, Inc. may need, and has the right, to clarify, amend, delete, or ed in the Employee Handbook. I agree to review the policy manual on a regular or on the FCCBH, Inc. web site, fourcorners.ws.

een FCCBH, Inc. and its employees is defined as an “at will” arrangement. n terminate employment for any reason or no reason. The FCCBH, INC. Board

ill” status in policy.

nt between employee and employer and there are no promises or r.

k”, understand how to access all FCCBH, Inc. policies and I further luded in this agreement explain that I am an at-will employee.

_________________ _______________________________________ Date

_________________ _______________________________________ Date

______________ _________________________________ Date

7/25/2003

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH POLICIES AND PROCEDURES

PERSONNEL, page 4 of 4

2.18 Information Technology (IT) Use Policy, Effective Date 1-18-2000

Employee Information Technology Assurance

I hereby acknowledge that I have read and agree to comply with the Four Corners Community Behavioral Health, Inc. Information Technology Policy and associated procedures and any future policies and procedures required to protect FCCBH, Inc. IT resources. I assure that I will access protected health information only as authorized according to standards defined in policy and procedure and acknowledge that inappropriate disclosure, access, alteration or destruction of PHI may be considered purposeful disregard and may result in disciplinary action or be cause for termination. I hereby acknowledge that upon severance from FCCBH, Inc. I will return all FCCBH, Inc. information technology property assigned for my use in working order to the Network Administrator or his / her designee on my last working day. I agree to compensate FCCBH, Inc. for lost or damaged property at replacement value. I agree that the cost of lost or damaged property shall be deducted from my final paycheck. Upon termination I will return all FCCBH, Inc. property immediately. Employee Name (Print) _____________________________________ Date____________ ______________________________________________________ Employee Signature ______________________________________________________ Supervisor Signature 4/17/2007

Four Corners Community Behavioral Health

Equipment Use and Return Assurance

It is the intent of Four Corners Community Behavioral Health to maintain the highest level of security and care for information technology equipment. The following standards are required for users of a lap top computer on loan from the Corporation.

1. The computer must be in a secure location or in the possession of the individual to who it is assigned at all times.

2. Extra pre-cautionary measures must be taken to protect the computer and its contents in public areas, at meetings, while traveling and in all other instances that may pose a security risk.

3. The computer is for the sole use of the individual designated by Four Corners Community Behavioral Health or Utah State University.

4. Computer disks that have been elsewhere should never be used in a Four Corners’ laptop unless the disk is subjected to a virus scan.

5. Downloading anything from the Internet is prohibited unless pre-authorized. 6. Installation of any software must be pre-authorized. 7. Lap top computers shall not be checked as baggage for air travel. 8. It is the responsibility of the user to take due care of the computer with regard to the investment of

the corporation in information technology equipment and to understand that resources may not be available to replace the computer for the individual’s use if it is beyond repair.

I hereby acknowledge that I have read and agree to comply with the Four Corners Community Behavioral Health, Inc. Equipment Use And Return Assurance and associated standards and any future policies and procedures required to protect FCCBH, Inc. IT resources. I hereby acknowledge that upon severance from the Utah Frontier Project and the Utah State University evaluation team I will return all FCCBH, Inc. information technology property assigned for my use to the Utah Frontier Project Coordinator or his / her designee on my last working day. Upon termination I will return all FCCBH, Inc. property immediately. Name (Print)___________________________________________ Date____________ _____________________________________________________ ________________________ Address Telephone ______________________________________________________ ________________________ Signature Title

3/2002

Four Corners Community Behavioral Health

Fire Drill Documentation

TO BE COMPLETED: JANUARY, APRIL, JULY and OCTOBER Facility in which drill was completed:_______________________________________ Person conducting the Fire Drill: _______________________________________ Did all persons leave the facility: YES NO Length of time for all persons to evacuate the building: _____________________ Did all employees ensure consumers in the facility were evacuated? YES NO Did all persons report to the area designated in case of fire evacuation? YES NO Comments and recommended follow‐up: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SIGNATURE OF RESPONSIBLE PERSON: ______________________________________________

12/2003

Health Insurance Acknowledgement

I hereby acknowledge that I am fully responsible for obtaining, reading, and understanding any and all information regarding the health insurance provided to me by FCCBH, Inc. I understand it is my responsibility to add and terminate dependents within the required time frames. I have read FCCBH policies 2.11 (Employee Termination Date and Benefit Termination) and 2.16 (Health Insurance Benefit Policy). I understand that COBRA continuation coverage may be an option once my employment has terminated. FCCBH is not liable for any expenses not covered by insurance. I have been provided with insurance booklets listing benefits and providers. These booklets contain contact information for the insurance companies so I may obtain any further clarification of benefits, providers and/or coverage. ___________________________________ ___________________________ Employee Signature Date

FCCBH, Inc.

INDIVIDUAL SUPERVISION LOG (Please Print)

Employee: Date: Time: __a.m. __ p.m.

Supervisor: Title: Program/Unit:

TOPICS DISCUSSED (Check All That Apply)

Clinical Supervision Utilization Management Time Sheet Timeliness Progress Notes Clinical Outcomes

Productivity Standard No Show Rate Payer Mix Caseload Consumer Satisfaction

Engagement Annual Leave Sick Leave Accuracy of Work Tardiness Attitude

Special Assignments Annual Goals Assessments Managed Care Plans Community Relationships

Behavior Other

Other Professional Development Goals

1. Summary of Topics (Issues/Needs in topics checked above) (Use reverse side of page if needed)

2. Accomplishments/Strengths/Progress Since Last Supervision

3. Action Plan (Complete if identified change needs require corrective action beyond this supervision session.) a. Specific Changes Required:

b. Performance Improvement Indicators Required (How will you know if the changes have been made?)

c. Date Corrective Action To Be Completed: d. Review Date:

4. Clinical Supervision Notes (Complete only if clinical supervision provided.)

5. Employee Comments:

Employee Signature Date Supervisor Signature Date 6/21/2006

FCCBH, Inc. INDIVIDUAL SUPERVISION LOG VERSION 2

(Please Print)

Employee: Date: Time: __a.m. __ p.m.

Supervisor: Title: Program/Unit:

TOPICS DISCUSSED For example: clinical supervision, utilization management, time sheet timeliness, progress notes, clinical outcomes, productivity standard, no show rate, payer mix, caseload, consumer satisfaction, engagement, annual leave, sick leave, accuracy of work, tardiness, attitude, special assignments, annual goals, assessments, managed care plans, community relationships, behavior, professional development goals, other.

1. Summary of Issues/Needs in topics checked above (Use reverse side of page if needed)

2. Accomplishments/Strengths/Progress Since Last Supervision

3. Action Plan (Complete if identified changes require corrective action beyond this supervision session.) a. Specific Changes Required:

b. Performance Improvement Indicators Required (How will you know if the changes have been made?)

c. Date Corrective Action To Be Completed: d. Review Date:

4. Clinical Supervision Notes (Complete only if clinical supervision provided.)

5. Employee Comments:

Employee Signature Date Supervisor Signature Date 6/21/2006

Four Corners Community Behavioral Health Leave Request

Employee: Date:

Type of Leave Requested

Total Days Dates of Leave Requested

Vacation Sick* Other Leave without Pay *Any sick time you may know about in advance i.e. Appointments, operations, etc.

Comments:

I may be reached at: Telephone: Address: Employee: Supervisor Approval: _______________________________ Date: _______________

10/2006

Four Corners Community Behavioral Health Application for Leave Bank Time

Name of applicant ________________________________________ Employee Number ____________ Date ____________ I am requesting a donation of hours from the FCCBH, Inc. Leave Bank because:

I have a major or severe illness or injury that is acute, life threatening or incapacitating and which reasonably would require me to be absent from work for an extended period of time. I have a serious chronic illness of long duration, causing serious debilitation or disability and / or acute persistent symptoms, which would reasonably require me to be absent from work for an extended period of time. A member of my immediate family (spouse or dependent) has a major or severe illness or injury that is acute, life threatening or incapacitating and which requires my care and I am needed to care for the family member. The family member is _______________________________________________________.

Facts that support my application for sick leave assistance:

________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Please attach the Leave Bank Medical Verification form to this application _____________________________________________ _________________________________ Employee Signature Date

SUPERVISOR’S RECOMMENDATION: Recommend Approval Recommend Denial _____________________________________________ _________________________________ Supervisor Signature Date Comments: _______________________________________________________________________________________________ EXECUTIVE DIRECTOR’S DETERMINATION: Approved Denied _____________________________________________ _________________________________ Supervisor Signature Date Comments: _______________________________________________________________________________________________ 1/21/2004

Accounting Office Only

Date Leave Bank donation is in effect ____________________ Copy sent to supervisor Copy sent to employee Accounting Operations Specialist _______________________

Four Corners Community Behavioral Health Leave Bank Donation Request

EMPLOYEE NAME

EMPLOYEE NUMBER

JOB TITLE

WORK SITE

I hereby donate _______________ hours of annual leave to the FCCBH, Inc. Leave Bank; AND / OR I hereby donate _______________ hours of converted sick leave to the FCCBH, Inc. Leave Bank; To provide an opportunity for paid leave for specific employees who have exhausted all personal leave, who meet the established criteria and are approved through the application process. I grant authorization to have this amount deducted from my leave balance(s). I understand that this authorization is strictly voluntary and is irrevocable and these hours will not be restored to my leave balances even if the leave is not used.

I understand that my donation will be included in a general pool for donation as approved by the Executive Director.

I request that my donation be made for the following individual if he or she is approved to receive donated leave from the leave bank. and I understand that any hours not used by the specified individual for the current approved application will revert back to the general pool. NAME OF APPLICANT____________________________________________________________________________________

I understand that I must have a balance of at least 80 hours of annual and / or sick leave after donation. EMPLOYEE SIGNATURE

DATE OF DONATION

Accounting Office Only Date leave donation deducted ____________________ Number of hours __________ Accounting Operations Specialist ______________________ Date leave donation added to Leave Bank ____________________ Accounting Operations Specialist ___________________________________ Leave donation held in the name of __________________________________________________________________________________________ FCCBH, Inc. Employee, Applicant for Leave Bank Donation

1/21/2004

Four Corners Community Behavioral Health Leave Bank Medical Verification

(To be completed by physician or licensed health care provider only)

Name of individual _______________________________________________________ Date ________________________ I certify that the individual listed needs to be absent from work for an extended period of time because:

The individual has a major or severe illness or injury that is acute, life threatening or incapacitating. The individual has a serious chronic illness of long duration, causing serious debilitation or disability and / or acute persistent symptoms. An immediate member of the individual’s family (spouse or dependent) has a major or severe illness or injury that is acute, life threatening or incapacitating and the immediate family member needs continuous care.

The family member is The spouse of the individual listed A dependent Medical facts that support the application for sick leave assistance for the individual listed:

________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Date individual became unable to work: ________________________________________________________________________ Expected date of return to work: ______________________________________________________________________________ _____________________________________________ _______________________________________ Name of physician or licensed health care professional Signature of physician or licensed health care professional _____________________________________________ Physician or health care provider’s phone

1/21/2004

MEDICAL RELEASE OF INFORMATION To be completed by Four Corners Community Behavioral Health employee

I authorize the release of the medical information on this form regarding myself, or my spouse or dependents living in my home, to be used for the purpose of establishing eligibility for use of sick leave from the FCCBH, Inc. leave bank. The information disclosed is confidential and is protected by Federal Law. ______________________________________________ __________________________________________________ FCCBH, Inc. Employee Other individual about whom medical information is provided Date _______________________________________________

Accounting Office Only Date received ________________________ Accounting Operations Specialist _______________________

Four Corners Community Behavioral Health Request for Increased Compensation at Licensure

Employee Position Date Request Submitted An increase is requested for the above named employee who has received licensure for the following: ______________________________________________________________________________________________

The criteria for determining the amount of increased compensation is as follows:

• Increases shall not differ from the terms of employment described in the letter of hire. • Increases may be granted according to an individual plan for obtaining a degree or licensure as approved by the supervisor and the Executive Director in

advance. • The most recent performance evaluation must be at least satisfactory and the employee may not be on corrective action.

An employee who receives the professional license related to their assigned duties and field of practice may be eligible for a salary increase. The increase may include one-step for every two years of employment with FCCBH. This is cumulative years for all time worked for FC. All years and months shall be rounded down to the next whole year (e.g., five years and seven months will be equal to five years for the purpose of calculating the increase.) An odd number of years will also be rounded down to the closest whole number (e.g., nine years divided by two is 4.5, this will be rounded down to four years.) Eligible employees will receive a minimum of a three-step increase. An employee who receives a degree related to their assigned duties and field of practice may be eligible for a salary increase. The increase may include one-step for every two years of employment with FCCBH. This is cumulative years for all time worked for FC determined as described above. Increase will be effective starting the pay period following the date license was received. Date license was received ___________________________ Supervisor’s Signature _________________________________________________________________________________ Increase is approved at Step _______________ Executive Director __________________________________________________________ Date ______________________________ 11/2001

Business Office Only: Amount of increase approved ____________________ Date to commence increase ________________________________ Technician __________________________

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH CENTER, INC.

New Employee Orientation Checklist All new employees of Four Corners Community Behavioral Health, Inc. should complete the following tasks and/or read the documents on this list. Each supervisor must assure that new employees complete these tasks and initial them in the space indicated. When all items have been initialed, the employee and the supervisor must sign and date this form. This checklist must be completed within one month of beginning employment and returned to the HR Manager. __________1. Compensation and Performance Management Philosophy

(Refer to tab #1 in binder) __________2. Read the Employee Handbook & give signed acknowledgement to HR Specialist (Given to every employee) __________3. Read the Corporate Mission Statement, Credo, Practice Principles, Service

Delivery Standard, and Quality Improvement Statement (Refer to tab #3 in binder) __________4. Review the current Center Organizational structure and organizational charts. (Refer to tab #4 in binder) __________5. Read the computer hints booklet and receive computer orientation from supervisor

or designee. (Refer to tab # 5 in binder & read the booklet that corresponds to your job) __________6. Receive and read relevant materials for Center and State vehicle orientation and

information. (Refer to tab #6 in binder) __________7. Read Center Practice Guidelines @ www.fourcorners.ws (clinical staff only) __________8. Read the mental health rights, policy on client grievance & the client grievance

handout. (Refer to tab #8 in binder) __________9. Fill out the “FCCBH Acknowledgement of Property Held by Employee” form. (Included in your new employee paperwork) _________10. 42 CFR Packet (Given to every employee) _________11. Application for Clinical Priveleges

8/2006

http://www.fourcorners.ws/

A. Required for all employees before hire date can be negotiated:

__________1. Employee data record __________2. I-9 form __________3. IRS form W-4 __________4. Copies of drivers license, social security card, resume,

degrees (if applicable) __________5. Current copy of clinical license __________6. Job description __________7. Drivers information sheet __________8. State Code of Conduct __________9. Center Drug Free Workplace Policy and pre-

employment drug test _________10. TB test results _________11. Direct deposit authorization form along with voided

check (checking account deposit) or voided deposit slip (savings account deposit)

_________12. Background Screening Consent and Release of Liability

Form (State Office of Licensing) _________13. Utah Retirement Forms (including 401-K and 457

participation forms for benefitted employees) and (Statement of Ineligibility for part-time hourly employees).

_________14. Information technology use policy _________15. Conflict of Interest/Related Party Declaration Form

_________16. Employee Confidentiality Agreement

8/2006

_________17. Employee Telecommunications Assurance _________18. Photograph of employee _________19. Biography of employee (one paragraph) _________20. Emergency contact information _________21. Cafeteria plan election agreement (benefitted

employees only)

_________22. Medical, dental, vision, and life insurance enrollment forms (benefitted employees only)

_________23. Health insurance acknowledgement (benefitted

employees only) To be completed by Supervisor before starting date can be negotiated: _________24. FLSA exemption declaration form (if employee is to be

classified as exempt) _________25. Payroll change notice _________26. Supervisor hiring checklist To be completed by HR Manager: _________27. Verification of non-disbarment

B. Optional personnel documents

__________1. 403-B application __________2. United Way contribution form (Carbon County only) __________3. Eastern Utah Community Federal Credit Union

deduction form __________4. Mountain America Credit Union deduction form

8/2006

__________5. Payroll withholding request form for BDAC, MRT Gym, Wellness Center (Carbon County only)

__________6. Deduction form for Unions, extra federal or state taxes,

other

___________________________________ _______________ Employee’s Signature Date ___________________________________ _______________ Supervisor’s Signature Date Received in HR Office ___________________ Date ____________________ HR Manager Initials

8/2006

Four Corners Community Behavioral Health, Inc. Performance Management One up Reviewer Guidelines

Name of employee being evaluated __________________________________ Date of evaluation ________________________ A one up review is conducted on each performance appraisal. The review is intended to provide another perspective on each evaluation. The Executive Director appoints appropriate one up reviewers, usually the appraiser’s supervisor.

Review the following guidelines and if yes or put X if no 1. Are ratings consistent? Are ratings for similar behaviors and/or competencies about the same?

2. Do goals have measurable outcomes?

3. Is there an indication that work related goals influenced ratings in Section I-A & B and Section 2?

4. Is there evidence that supports the ratings on training and professional development goals?

5. Is there fairness within each work group (i.e. point totals correspond to recommended activities)?

6. Was the direct service hours performance standard met at a satisfactory level or above?

7. On the Engagement page, was # 4, Employee shows respect, courtesy and is highly responsive to all Constituents rated at 4 or above.

8. Are there one or more points on progress toward Training and Professional Development Goals?

9. Did the supervisor write “No” on the line following No formal corrective action plans during the year.

10. Did the supervisor include: “Recommended quartile placement: From: __________To: ________ Recommended increase from spreadsheet: From: ____________ To: ____________”

Explanation for # 10 above: Recommended quartile placement: From: Current placement here To: New placement recommendation here Recommended increase from spreadsheet: From: Current wage here To: New wage here

Does the spreadsheet correlate to the quartile placement? _____ Yes _____ No

Appropriate one up review comments include: Confirmation that goals are measurable and there is evidence of progress or if the opposite is true; observe how appraisal is consistent and/or fair if true; note if required criteria are met; point out any outstanding features of the evaluation and/or sections that need attention.

Signature of reviewer ____________________________________________ Date ____________________________

Revised 6/19/2007

Four Corners Community Behavioral Health, Inc. Other Trained Staff Certification - Tracker

ame of the employee working towards “other trained” certification by FCCBH, Inc. Requirements for “other trained” de on the job training and staffing cases under the supervision of a licensed professional; TCM and SDS training and lopment Institute modules as assigned. Completion of requirements should be tracked on this form. Other trained n will be presented upon completion.

________________________ _____________________________ ____________________________________ Date Submitted to Training Officer Training Officer & Date Received

Training Re Specifications Date Supervisor

Other Train1 On the job tr icensed staff supervision (LCSW, CSW, RN, SSW, LSAC, LPC, Ph.D.); sign off 2 Staffing case irect supervision by a licensed mental health therapist; sign off 3 TCM Traini avigating the Maze of Community Services through TCM; classroom / test – certificate 4 TCM/SDS T DS interventions; social, living skills; boundaries; MCPs; classroom – certificate 5 TCM/SDS T risis intervention; understanding mental illness; progress notes; classroom – certificate

PACKETS R TRAINING MODULES ARE AVAILABLE IN THE TRAINING FILE IN HR SDI trainin ervisor (employees must complete at least five modules for “other trained” certification and complete 2 additional

modules eac ach module is available through the training officer. 6 Medicaid Me orners.ws – 1.5 hrs Read Medicaid Member Handbook (19 sections) 7 Mental Health & @ fourcorners.ws – 2 hrs Review MH Advance Directive training packet; complete sample document 8 Recovery & m discussion – 2 hrs Read SAMHSA Self-Help Guide/Crisis Planning Packet, lead team discussion 9 First Aid Tra mplete class – 8 hrs Complete and pass First Aid Training; local fire dept.; provide copy of card 10 CPR Indepe – 4 hrs Complete and pass CPR Training; local fire dept.; provide copy of card 11 Mediation/C ule – 2 hrs Complete Peer Mediator Training Workbook; complete sample document 12 Coaching the e – 1.5 hrs Driver safety required for FC or State vehicle drivers – get CD from HR 13 Cultural Com discussion – 1 hr Lead team meeting cultural competency discussion using guides in packet 14 42 CFR / Co nd ongoing TA – 2 hrs Read 42 CFR TA Publication USDHHS packet ; provide ongoing TA 15 Job Safety S – 1 hr Review Job Safety and Dealing with Emergencies training; test 16 Living with View NDBSA Dark Glasses and Kaleidoscopes to enhance knowledge 17 Strengthenin uss w/ supv – 2 hrs Read NMHA Strengthening Families fact sheets packet; identify uses; discuss w/ supv 18 Break Throu and practice – 20 min. View Break Through Listening video; practice 4 things learned 19 Time Manag ractice – 26 min. View Time Management video; practice 4 things learned 20 Social Secur and ongoing TA – 1.5 hrs Review SSA consumer materials/fact sheets on SSI/SSDI packet; provide ongoing TA 21 Anxiety Dis s w/ supv – 1.5 hrs Read NIMH fact sheets on 5 anxiety disorders, identify uses packet; discuss w/ supv 22 Schizophren View The Science of Schizophrenia video to enhance knowledge

10/2006

Write the nstaff incluStaff Devecertificatio _________Supervisor

quirement (& estimated time) ed Staff Core Requirements aining (100 hrs) Ls (12 hrs) D

ng and Manual (3 hrs) Nraining (3 hrs) Sraining (3 hrs) C AND INSTRUCTIONS FOg modules to be assigned by suph year.) A training packet for ember Handbook Self study @ fourc Advance Directive Self study module Prevention Self study module, teaining Independently enroll in/condently enroll in/complete classonflict Resolution Self study mod Experienced Driver On-line courspetency Self study module, team

nfidentiality Self study module aelf study @ fourcorners.ws /test

Bipolar Review video – 33 min.g Families Self study module, discgh Listening Review DVD, learnement Review DVD, learn and pity Disability Self study module orders Self study module, discusia Review video – 47 min.

A. Required for all employees before hire date can be negotiated:

__________1. Employee data record __________2. I-9 form __________3. IRS form W-4 __________4. Copies of drivers license, social security card, resume,

degrees (if applicable) __________5. Current copy of clinical license __________6. Job description __________7. Drivers information sheet __________8. State Code of Conduct __________9. Center Drug Free Workplace Policy and pre-

employment drug test _________10. TB test results _________11. Direct deposit authorization form along with voided

check (checking account deposit) or voided deposit slip (savings account deposit)

_________12. Background Screening Consent and Release of Liability

Form (State Office of Licensing) _________13. Utah Retirement Forms (including 401-K and 457

participation forms for benefitted employees) and (Statement of Ineligibility for part-time hourly employees).

_________14. Information technology use policy _________15. Conflict of Interest/Related Party Declaration Form

_________16. Employee Confidentiality Agreement _________17. Employee Telecommunications Assurance _________18. Photograph of employee

12/2003

_________19. Biography of employee (one paragraph) _________20. Emergency contact information _________21. Cafeteria plan election agreement (benefitted

employees only)

_________22. Medical, dental, vision, and life insurance enrollment forms (benefitted employees only)

_________23. Health insurance acknowledgement (benefitted

employees only) To be completed by Supervisor before starting date can be negotiated: _________24. FLSA exemption declaration form (if employee is to be

classified as exempt) _________25. Payroll change notice _________26. Supervisor hiring checklist To be completed by HR Specialist: _________27. Verification of non-disbarment

B. Optional personnel documents

__________1. 403-B application __________2. United Way contribution form (Carbon County only) __________3. Eastern Utah Community Federal Credit Union

deduction form __________4. Mountain America Credit Union deduction form __________5. Payroll withholding request form for BDAC, MRT

Gym, Wellness Center (Carbon County only) __________6. Deduction form for Unions, extra federal or state taxes,

other

12/2003

___________________________________ _______________ Employee’s Signature Date ___________________________________ _______________ Supervisor’s Signature Date Received in HR Office ___________________ Date ____________________ HR Specialist Initials

12/2003

Non-Exempt Employees Overtime Pre-authorization

I authorize _________________________ to work ____________ additional hours for Name of employee Number of hours the week of ________________________. I understand that by law FCCBH, Inc. is (Sunday through Saturday) required to pay the non-exempt employee 1.5 times their regular hourly rate for each hour worked over forty hours and this is ___________ hours over the allowable hours for the week. The employee must work these additional hours for the purpose of _________________ _______________________________________________________________________ FCCBH, Inc. policy states that overtime is allowed only when there are no other options available to get the work done. This employee could not accomplish the work assigned in the job description within the hours allocated because ____________________________ _______________________________________________________________________ The Overtime Policy 2.22 has been reviewed with this employee. __________________ Initials of Supervisor and Employee Pre-authorization for overtime must be submitted to the payroll office by the close of the business day on Friday. _____________________________________ ______________________________ Signature of Supervisor Signature of Employee 10/2004 Payroll Office Use Only Time Received_____________ Date _______________Fax ___ Inter-office mail ___ Person ___ Payroll Representative ________

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH POLICIES AND PROCEDURES

2.27 SEXUAL HARASSMENT PREVENTION, Effective Date: 3-21-2000 I hereby acknowledge that I have read the Four Corners Community Behavioral Health, Inc Sexual Harassment Prevention Policy and I understand it. I also agree to comply with the policy and associated procedures. Employee Name (Print)____________________________________________________ Employee Signature________________________________ Date__________________ Supervisor Signature_______________________________________________________

6/18/2004

FCCBH - SUPERVISION TRACKING FORM NAME:___________________ MONTH/YEAR________ Week 1 Week 2 Week 3 Week 4 Week 5 First party collection report Days to next open intake and med evaluation High risk cases (as required) P-code reports year to date and previous month ------- ------- ------- ------- J-code report (Emery) ------- ------- ------- ------- Contract reports ------- ------- ------- ------- Staff productivity reports previous month -------- ------- ------- ------- Staff caseload reports with supervision notes ------- ------- ------- ------- Staff supervision review ------- ------- ------- ------- IOP Capacity and current statistics ------- ------- ------- ------- Intake no-show report previous month ------- ------- ------- ------- Clubhouse capacity and statistics ------- ------- ------- ------- COTT capacity and statistics ------- ------- ------- ------- Budget year-to-date and previous month ------- ------- ------- -------

2/02

Four Corners Community Behavioral Health, Inc. SUPERVISOR HIRING CHECKLIST

Please fill out, attach the documents listed and send to the Human Resources Office: ______ Hiring authority, Date __________ ______ Job description ______ Screening committee selected and notified (list names/affiliations)

____________________________ ___________________________

____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ____________________________ ___________________________ ______ Pre-employment phone reference checks (must have a minimum of 2 references

documented)

Mentor assigned to work with new employee ____________________________ Name

1/17/2007

FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH

POLICIES AND PROCEDURES

Finance, page 4 of 4

3.15 Telecommunications, Effective Date: 7/1/80

Employee Telecommunications Assurance

I hereby acknowledge that I have read and agree to comply with the Four Corners Community Behavioral Health, Inc. Telecommunications Policy and associated procedures. I hereby acknowledge that upon severance from FCCBH, Inc. I will return all FCCBH, Inc. telecommunications property assigned for my use to the Associate Director for Administrative Services or his / her designee on my last working day. Upon termination I will return all FCCBH, Inc. property immediately. _____________________________________________________ _______________ Employee Name (Print) Date ______________________________________________________ Employee Signature ______________________________________________________ Supervisor Signature

TRAINING AUTHORIZATION

EMPLOYEE NAME _________________________________________________________________

TRAINING TITLE _________________________________________________________________

TRAINING LOCATION (CITY&STATE) _______________________________________________

HOTEL NAME _________________________________________________________________

REGISTRATION PAYABLE TO ____________________________________________________________________________________________________________________________________________________________

TRAINING DATE(S)___________________

REGISTRATION COST: $____________________TRAVEL COST:

MILEAGE $____________________

AIRFARE $____________________

LODGING $____________________

MISC_______________________ $____________________

MEALS $____________________

TOTAL ESTIMATED COST $____________________

EMPLOYEE SIGNATURE______________________________________ DATE_____________

I have reviewed the training authorization & this employee's training expense log for the past year and approve of this request.

SUPERVISOR SIGNATURE_____________________________________ DATE_____________

ATTACH A COPY OF CONFERENCE REGISTRATION AND TRAINING AGENDA.

RATE GUIDELINE: IN STATE MEALS: OUT OF STATE MEALS: MILEAGE: BREAKFAST $ 6 BREAKFAST $ 9 NO CENTER CAR AVAILABLE $.40 PER MILE LUNCH $ 9 LUNCH $ 11 CHOSE TO DRIVE OWN VEHICLE $.28 PER MILE DINNER $15 DINNER $ 18 *PREMIUM CITIES (Chicago, New York, Washington D.C., Atlanta, San Francisco, LA & Boston) - out of state perdiem or actual receipts up to $50 per day

LODGING: PRIVATE RESIDENCE $20 IN & OUT OF STATE HOTEL $68

EVENT SITE - ACTUAL COST * NON EVENT SITE (IN & OUT OF STATE) - COST UP TO EVENT SITE RATE*

* MUST HAVE PRIOR APPROVAL & MUST DOCUMENT CONFERENCE SITE RATE (CONFERENCE BROCHURE) CAMPGROUND $30

NOTE: ALWAYS ASK FOR THE STATE RATE. IF THE HOTEL DOES NOT OFFER A STATE RATE, ASK FOR A CORPORATE RATE. PHONE: 4 nights or less (requires receipts) - up to $10 5 nights or more (requires receipts) - up to $20

*This form is not a substitute for PR's or the travel reimbursement form.*This form must be approved by your supervisor and sent to administration with any required PR's (registration, motel, airfare, etc.) and the travel reimbursement form before attending training.

THIS FORM IS NOT REQUIRED FOR ADMINISTRATIVE MEETINGS & CONFERENCES5/12/04

Four Corners Community Behavioral Health Work Time Variance Request (Variance from regular hours)

Date: __________ Year: ___________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday TOTAL Start End HOURS

Reason ______________________________________________________________________ _____________________________________________________________________________ Date: _________________

Sunday Monday Tuesday Wednesday Thursday Friday Saturday TOTAL Start End HOURS

Reason ______________________________________________________________________ _____________________________________________________________________________

Employee Date Supervisor Date 7/2002

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