INFORMATION SHEET
*  
*Sponsor Facility: *Sponsor Division: *Sponsor Name:

As appeared on your identification card:
*1. Last Name: *First Name: MI: *Gender: *Social Security Number:
   -     - 
Other Name(s) Used: Marital Status: Ethnicity:
*2a. RESIDENCE - Street and Number: *City: *State: *Zip:
2b. Date Residency established in California: 2c. Date Residency established in Los Angeles County:
*3a. Do you have a relative currently employed by the County ?
 If yes*, indicate Name, Relationship And Department:
 
*3b. Have you ever worked previously or currently for the County as an employee or contractor   (including independent or agency)?
Employee No. Department Name Date worked (From/To)
If so*, provide:
4.*Date of Birth: *Telephone No : *Email Address:
  *Name: *Telephone No.:
*5. In case of emergency, notify:
Street and Number: City, State, and Zip:
6.  Credential Type: Identification No.: Identification Issued From (Country /State):
7. Education (Name and location of School) Last Grade Completed Date Completed College Major Degrees or Diploma
Grammar and High School 
College/University   
Other  
Other  
*8. Do you have a Professional or Technical Licenses, Permit, etc., that is required for this position?
License Serial No. Expiration Date Board Agency State, County, or City which registered
9. Employment History: Begin with present of last experiencee Account for past ten years or past ten employers.

From
Mo-Yr
To
Mo-Yr
Time In
Mos.
Position or
Occupation
Duties performed in each employment Wages of
Salary
Name and addresses of all
former employers including other
County depts. As well as private
firms.
Reason
for
Leaving
10. If discharged, give detail. Do not provide criminal conviction informatiion. (REQUIRED, limited 500 characters)
    
PARENTAL CONSENT FOR MINORS
A. I have read this form "Parental Consent for Health Evaluation" and given Los Angeles County Department of Health Services permission to conduct a criminal background check, obtain medical informaiton and/or provide medical care/screening for a minor applicant. Parent or legal responsible person must sign "Parental Consent for Health Evaluation" form in the presence of DHS Human Resources staff and show identification. Print out this form and bring it with you to Human Resources for in-processing.  Click here to read
CONDITION OF ASSIGNMENT FORMS (Check One)
1.   I have read this form "Acknowledgment of Conditions of Assignment (Voluntary Attending Staff)" and I agreed to the conditions of County assignments listed.  Click here to read
2.   I have read this form "Acknowledgment of Conditions of Assignment (Contract/Registry Staff, Non-County Residents/Fellows/Affiliates)" and I agreed to the conditions of County assignments listed.  Click here to read
3.   I have read this form "Acknowledgment of Conditions of Assignment (Volunteers, Students)" and I agreed to the conditions of County assignments listed.  Click here to read
4.   I have read this form "Acknowledgment of Conditions of Assignment Independent Contractors" and I agreed to the conditions of County assignments listed.   Click here to read
LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check One)
1.   As a Voluntary Attending Staff member, I am an officially enrolled Volunteer of the County, and I understand that the County will defend and insure me against any liability resulting from an act or omission occurring during the course and within the scope of my practice within any County facility. I also understand, however, that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.
2.   I am a Contract/Registry Staff, Non-County Residents/Fellows/Affiliates, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my employer or academic institution, unless otherwise contractually provided, and the County of Los Angeles shall be held harmless and will not defend or insure me in any action taken against me as a result of my acts or omissions, whether conducted within, or outside of, my approved scope of practice, within any County facility.
3a.   I am a student, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my sponsoring academic institution, agency or employer, unless otherwise contractually provided. The County of Los Angeles shall be held harmless and will not defend or insure me against any liability resulting from any act of mission whether arising within, or outside of, the course of scope of my assignment.
3b.   I am an officially enrolled Volunteer of the Los Angeles County Department of Health Services, and I understand that the County will defend and insure me against any liability resulting from an act or omission occurring during the course and scope of my volunteer work assignment. I also understand, however, that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.
4.   I am an Independent Contractor, and I understand I am responsible for providing and maintaining each of the types and limits of commercial insurance coverage which are specified by the terms of my County service agreement/contract unless otherwise provided or waived by the County. The County of Los Angeles shall be held harmless and will not defend in any action taken against me as a result of my activities within any County facility.
SCOPE OF ASSIGNMENT (Check One)
  The scope of my assignment involves direct patient care activities for which I will maintain current licensure, certification, registration, and/or permit without restriction and provide adherence to the apporpriate authorities at the medical center or facility.
    The scope of my assignment does not involve direct patient care duties, although if my assignment requires licensure, certification, registration and/or permit, I will keep it current and without restriction.
MANDATORY FORMS [ALL CHECKBOXES MUST BE CHECKED]
*5.   I have read this Policy Statement "Non-County Workforce Comprehensive Policy Statement (CPS)" and agreed to the conditions of County assignments listed.   Click here to read
*6.   I have read and reviewed the "Code of Conduct" guidance from DHS Compliance Program and acknowledged the standards and principles for the ethical and legal conduct. I acknowledge that I will complete the online Compliance Awareness Training within 60 days of my assignment date.   Click here to read
*7.   I have read and reviewed the "Patient Privacy & Confidentiality Packet" and agreed to abide by the policies and procedures.   Click here to read
*8.   I have read this County Policy of Equity and agreed to adhere to the County Policy of Equity.  Click here to read
*9.   I have read and reviewed DHS Policy 708.000 on Nepotism. Click here to read
*10.   Print out Non-County Packet and bring it with you to Human Resources for in-processing. Click here to read
*11.   I have read and reviewed the Patient Safety Click here to read  and Risk Management handbooks Click here to read  and agree to abide by the contents of those handbooks. 
   *    I CERTIFY THAT ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
  
SPONSOR USE ONLY
Candidate's Employment Type:
Candidate's Agency: 
Candidate's Job Title:
Candidate's Department:
Candidate's Contract Length:  days
         Sponsor's Comment:
Check here if Candidate's supervisor name same as Sponsor's
Candidate's Supervisor's First Name Candidate's Supervisor's Last Name Candidate's Supervisor's Email
I have reviewed the information provided on this form. Based on my review, I APPROVE this online form.
I have reviewed the information provided on this form. Based on my review, I DO NOT APPROVE this online form.
SPONSOR USE ONLY
* Required Field  

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