Healthcare Health Promoters Form

HEALTHCARE HEALTH PROMOTERS FORM

Promoter Identification

Date of Birth:     Gender:

Primary Phone:     Email:

Assignment & Program Details

Position / Title:     Employment Status: Employee Contractor Volunteer

Assignment Start Date:     Expected End Date (if any):

Licenses, Training & Certifications

Highest Level of Education:

CPR   Date:

First Aid   Date:

Other certifications:   Date:

Medical & Immunization Information

COVID-19 vaccination:    TB screening (TST/IGRA):

Hepatitis B:

Background Check, Screening & Authorizations

I authorize the program and its agents to obtain and verify background information, employment history, education, licensure, certification, and to conduct criminal background checks and drug screening where permitted by law. I understand that a disqualifying result may affect assignment or continuation in the program.

I consent to background checks and credential verification

Do you carry professional liability insurance? Yes No

Confidentiality & HIPAA Acknowledgment

As a health promoter, I may have access to Protected Health Information (PHI) only as required to perform assigned duties. I agree to:

1. Maintain confidentiality of all PHI and comply with applicable privacy and security policies;
2. Access only the minimum necessary information needed to perform my duties;
3. Not disclose PHI to unauthorized persons or use PHI for personal gain;
4. Report any suspected privacy or security incidents immediately to the program supervisor.

I understand that violation of these terms may result in disciplinary action up to and including termination, and potential civil or criminal penalties under applicable law.

I acknowledge that I have received and completed required privacy and HIPAA training for my role or will complete it prior to receiving PHI access.

Emergency Contact

Relationship:     Phone:

Agreement & Authorization

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the program to verify any information provided, contact references, and obtain credentialing and background information as necessary for my assignment. This authorization shall remain in effect for the duration of my assignment unless revoked in writing, provided that such revocation will not affect any action taken in reliance on this authorization prior to revocation.

I understand that completion of this form does not guarantee placement and that the program may impose additional screening, training, or immunization requirements prior to assignment.

Optional: Additional Notes

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