Policy Manual sample

MDT Home Health Care Agency, Inc. PRN QUESTIONNAIRE Name: _____________________________________________________________________________ (Please Print) Discipline/Title: ______________________________________________________________________ Please complete the following questionnaire by circling your response. Please comment as appropriate. · What days and hours are you available to work? (circle all that apply) Mon Tue Wed Thur Fri Sat Sun AM AM AM AM AM AM AM PM PM PM PM PM PM PM · Are you available to work weekends? Yes No If yes, specify how often: _______________________________________________________________________________ ___________________________________________________________________________ · How much notice do you require for a coverage request? _______________________________________________________________________________ ___________________________________________________________________________ · How far stated in miles or hours are you willing to drive for coverage needs? ________________ Miles ________________ Hours · Are you willing to work holidays? Yes No If yes, please specify which one(s): _____________________________________________________________________________ ______________________________________________________________________________ · When is the best time to contact you? _____________________________________________________________________________ ______________________________________________________________________________ · Please list all contact phone numbers: Home: ____________________ Pager: ____________________ Cell: ____________________ Other: ____________________ Message: ____________________ If calling work is acceptable please list work telephone number and specific protocol: ______________________________________________________________________________ ______________________________________________________________________________ Signature: ___________________________________ Date: ___________________________ Home Health Agency. - - Personnel/Operations Policies B-116