New Employee Department Specific / Job Specific Orientation
Community Physician Network
Employee Name:_____________________________________________ Employee ID# __________________
Classification:_____________________ Location/Supervisor: ____________________________________
Action: New Hire _____ Rehire _____ Transfer in _____ Effective Date: __________________________
Appointment type: Career ______ Limited ______ Work Study ______ Contract ______ Per Diem ______
Scheduled for New Employee Orientation: Yes _____ No _____ N/A _____ Date: ______________________
Please complete all sections with in the first 30 days of employment and return to Human Resources
Human Resources
Coordinator / Employee
I. New Hire Initial Paperwork - Human Resources initials
Employee Data Form / Prior State of California Service Credit Verification Form
Form I-9 Employment Eligibility Verification
Demographic Data Transmittal Form
UC - W-4/DE4 Withholding Allowance Certificate
State Oath of Allegiance, Patent Policy and Patent Acknowledgement
Payroll Wage Disposition Request Form - Surepay - w/Payroll Calendar
Confidentiality Agreement Form
Abuse Reporting Requirement Forms (Child, Elder, Domestic)
Code of Conduct - Corporate Compliance Handbook (http://www.mednet.ucla.edu/ComplianceQuiz/)
Faculty Practice Group - PSS or CPN Work Rules
World Class Practices - My Commitment to Care
UCLA Health System Photo ID Application Form
New Employee General Orientation Information (location, date and time)
Parking Coordinator /
II. New Hire Initial Paperwork - Building and Parking Services Employee initials
Orientation for Faculty Practice Group Parking at LAX/Spectrum Building
UCLA Parking and Commuter Services Payroll Deduction Authorization Form
Standard Parking Airport Spectrum Access Card Request Form
Human Resources
Coordinator / Employee
lll. Information/Booklets/Pamphlets Given to New Hire initials
Your Group Insurance Plans Booklet w/ Medical Benefits Summary and Calculation Rate Charts
At Your Service pamphlet (http://atyourservice.ucop.edu/)
Benefits Enrollment Reminder
Facts About Workers Compensation
Employee Required Trainings: HIPAA Education & Training; Compliance Quiz (http://www. mednet.ucla.edu)
Payroll Coordinator /
IV: Payroll Process: David Geffen School of Medicine (DGSOM) Employee initials
DGSOM Timesheet Submission Process Review
At Your Service (Bencom) (http://atyourservice.ucop.edu/)
1 Place Original in Employee File
New Employee Department Specific / Job Specific Orientation
Community Physician Network
Employee Name:_____________________________________________ Employee ID# __________________
Classification:_____________________ Department/Supervisor: ____________________________________
Unit Representative /
V. UNIT & JOB SPECIFIC ORIENTATION Employee initials
Job Description / Performance Expectation / Evaluation Review Process Review
Competency Assessment Instrument / Review Process Review
Work Area Tour
Staff Communication ( Vacation request; LOA request; Workers Comp Injury Report;)
Departmental Policies and Procedures
1. Work Rules
2. Personnel Contracts/Policies
Unit Representative /
VI. MANAGEMENT OF ENVIRONMENT OF CARE Employee initials
Safety Management
1. Office/Unit/ Department/Floor Safety
2. Body Mechanics – Requesting an Ergonomics Evaluation
Security Management
1. Reporting Crimes
2. Keys
Fire Prevention
1. Fire Drills
2. Reporting a fire
3. Location of closest exit and exit procedure
4. Location of Fire Extinguisher
Emergency Management
1. Location of Disaster Plan
2. Location of Emergency Supplies/First Aid Kit
3. Earthquake Supplies
4. Evacuation Procedures
Utilities Management / MCCS Management
1. Procedure in the event of a malfunction /error message / no service
VII. Other - Clinic Location Specific
_________________________________________________
Employee Signature Date
_________________________________________________
Supervisor / Manager Signature Date
2 Place Original in Employee File
New Employee Department Specific / Job Specific Orientation
Community Physician Network
3 Place Original in Employee File
New Employee Department Specific / Job Specific Orientation
Community Physician Network
4 Place Original in Employee File