Confidentiality/HIPAA & Drug-Free Workplace & Injury Policy Acknowledgements

2021

This survey covers two annually-required subjects:

Confidentiality/HIPAA
Drug-Free Workplace/Injury Policy

*There is no test or anything you need to send anyone - simply check every box then hit "Done" to submit your information.

Regarding Confidentiality/HIPAA:
By signing this electronic agreement/completing the survey, you agree to adhere to Frontier Community Services' Employee Confidentiality practices, have been given the Notice of Privacy Practices Summary Consent Form to review, and agree to the HIPAA Memorandum of Understanding that you may use protected health information only in the provision of services to someone. All of the aforementioned documents and supplemental training material can be found here: https://www.frontiercommunity.com/confidentiality-hipaa

Regarding Drug-Free Workplace:
By signing this electronic agreement/completing this survey, you agree to adhere to Frontier Community Services' Drug-Free Workplace Policy and reviewed the policy here: https://www.frontiercommunity.com/confidentiality-hipaa

If you have any questions or concerns, please contact our HR department at 740-772-1396.

Question Title

* 1. What is your contact information & the date you completed this Acknowledgement?

First Name *

Last Name: *

Job Title: *

Today's Date:

Email Address: *

Phone Number: *

Question Title

* 2. By checking each box, I agree & understand the following practices with regard to Confidentiality/HIPAA:

Frontier Community Services and its employees will protect confidential information including, but not limited to, the people we support, employees, and administrative information or issues.

I acknowledge that it was explained to me the need for safeguarding confidential information to which I have access, whether verbal, written, electronic, or in any other form.

I understand that access to and collection, retrieval, or dissemination of any such information, except in the course of and for the purpose of performing my duties, is expressly prohibited. If I am unsure of my authority or responsibility in this regard, I will consult with my supervisor or designee.

I agree to comply with Frontier Community Services policies and procedures in regard to safeguarding confidential information.

I understand that failure to adhere to the Frontier Community Services' confidentiality policy and provisions of State and Federal law may result in disciplinary action up to and including dismissal. I also understand that the unauthorized disclosure of confidential information may result in civil or criminal penalties as set out in law.

Question Title

* 3. By checking each box, I agree/understand:

I have reviewed, and had explained to me, Frontier's Notice of Privacy Practices Policy.

I have reviewed, and had explained to me, my Individual Rights.

I have been given the opportunity to have my questions answered.

I understand that I can contact my supervisors with questions, but Frontier’s Privacy Control Officer has been identified as Brian Sylvester, Operations Manager, who can be reached at 740-772-1396.

I understand that I have the right to revoke my authorization at any time, except to the extent we have already relied on it in making an authorized use or disclosure.

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* 4. By checking each box, I agree/understand:

I am considered a HIPAA Business Associate of the Health Care Components of Frontier Community Services. A Business Associate is defined in HIPAA regulations, codified in 45 CFR Part 164.

As a Business Associate, I agree to all the requirements pertaining to the protection of Personal Health Information of the people/clients I may assist.

The permitted uses of people I support/client's protected health information Under 164.504 (e)(2)(i) are as follows: I may use protected health information for the provision of services to people I support/clients of Frontier Community Services, per the training received on the date indicated above.

Question Title

* 5. By checking each box, I acknowledge:

I have received a copy of Frontier Community Services’ (Frontier) Drug-Free Workplace Policy.

I have had the opportunity to discuss the policy, and I understand all of the provisions contained herein.

I understand that although the policy reflects Frontier’s current policy regarding substance use, it may be necessary to make changes from time to time to best serve the needs of the Agency. However, any changes deemed necessary will be made in writing, and the modified policy will be shared with every employee.

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* 6. By checking each box, I am acknowledging that I understand Frontier's Injury Procedure:

I understand that if I am injured at work, I am required to contact my supervisor as soon as possible, but contact has to be made before the end of my shift and within 24-hours of the injury.

If my injury requires treatment, I understand that I am required to contact Human Resources and submit all of the medical paperwork to my Program Manager or the Human Resource office on the day of treatment. I can submit them via email or hand-deliver them.

If I am involved in any traffic accident during scheduled work hours, receive a warning, ticket, or citation, I must bring a copy of any documentation and report it to HR as soon as possible, and I must report for a substance abuse screening.

If I am injured during work hours, I must complete an incident report describing the situation.

If I am injured during work hours, I will be asked to go to the Occupational Health Department of Adena Health System (or ER if Occupational Health is closed), and let them know I work for a drug-free workplace. Adena Health System/the ER will complete a "First Report of Injury" form, and a drug screening will occur at that time.

Question Title

* 7. By checking each box, I am acknowledging that the reasons for drug testing include:

New Hire

Post-Accident

Reasonable Suspicion

Return-to-Work or Follow-Up

MUI Investigations

Transportation Incidents