Healthcare Training Packet

HEALTHCARE TRAINING PACKET

Facility Name:   Department:

1. Employee Information

Date of Birth:   Gender:

Primary Phone:   Email:

Relationship:   Phone:

2. Training Modules Completed

Orientation & Facility Policies   Date Completed:

Hand Hygiene & Infection Control   Date Completed:

Bloodborne Pathogens & Exposure Control   Date Completed:

HIPAA Privacy & Security   Date Completed:

Patient Safety, Falls Prevention & Emergency Procedures   Date Completed:

Medication Safety & Administration (if applicable)   Date Completed:

3. Competency Assessment

For each checked module above, the employee has demonstrated required skills and knowledge to the satisfaction of the trainer. Trainer to initial and date each demonstrated competency where applicable.

Trainer Title:   Trainer Initials:   Date:

4. Acknowledgments, Policies, and Certifications

I acknowledge that I have attended the trainings indicated above, received copies of applicable policies and procedures, and have had opportunity to ask questions. I certify that I understand the content presented and that I will comply with all facility policies, state and federal law, and standards of professional conduct while performing my duties.

Confidentiality and Protected Health Information: I understand my ongoing obligation to protect patient information. I will access, use and disclose protected health information only as permitted by law and facility policy. I understand that improper use or disclosure may result in disciplinary action, up to and including termination, as well as civil or criminal penalties.

Infection Control and Exposure: I acknowledge instruction on exposure prevention and post-exposure procedures. I will immediately report incidents of exposure or potential exposure and will comply with post-exposure evaluation and treatment as required by facility protocol.

Mandatory Reporting: I understand mandatory reporting obligations for abuse, neglect, or other reportable conditions in accordance with applicable laws and facility policy. I will timely report any suspected incidents to the appropriate authority.

Training Records and Re-Training: I understand that the facility will retain training records in my personnel file. I understand that certain competencies require periodic re-training and that failure to complete required re-training may affect my privileges or employment status.

Certification Valid Until:   Next Required Renewal:

5. HIPAA / Privacy Acknowledgment

I acknowledge that I have received instruction regarding HIPAA privacy and security rules, that I understand my obligations to safeguard protected health information, and that violations will result in disciplinary action.

HIPAA Authorization Expiration Date (if applicable):

6. Health & Immunization Status (Documentation May Be Required)

TB Screening Completed: Yes   Date:

Influenza Vaccination: Received   Date:

Hepatitis B Vaccination Series: Offered/Declined (mark applicable)

7. Notes / Supervisor Comments

8. Employee Attestation and Signature

By signing below I attest that the information provided in this Healthcare Training Packet is true and complete to the best of my knowledge; that I have completed the training indicated; and that I accept responsibility to apply this training in my performance of duties. I understand that falsification of training records or refusal to comply with required training may result in corrective action, up to and including termination.

Sign Now