NEW EMPLOYEE
PERSONAL DATA SHEET
Name: ____________________________________________ SS # ______________________
Address: _____________________________________________________________________
Town: _____________________________ State: _____________ Zip Code: ______________
Home Phone: __________________________ Date of Birth: ___________________________
PERSON TO NOTIFY IN CASE OF AN EMERGENCY:
Name: ______________________________________ Relationship: _____________________
Address: _____________________________________________________________________
Town: _____________________________ State: _____________ Zip Code: ______________
PHONE NUMBERS:
Day: __________________________________ Evening: ______________________________
RACIAL IDENTIFICATION (for federally required reporting)
____ Caucasian
____ Asian
____ Black
____ American Indian
____ Hispanic
____ Cape Verdean
MARITAL STATUS
____ Single
____ Married
If you would be willing to serve as a translator for the hospital, please indicate the languages
you are fluent in below.
LANGUAGES: ______________________________________________________________
Form W-4 (2014)
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal income tax from your
pay. Consider completing a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2014 expires
February 17, 2015. See Pub. 505, Tax Withholding
and Estimated Tax.
Note. If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,000 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
iincome, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2014. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $65,000 ($95,000 if married), enter “2” for each eligible child; then less “1” if you
have three to six eligible children or less “2” if you have seven or more eligible children.
G
• If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter “1” for each eligible child . . .
a
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)
H
A
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
a Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
Last name
Home address (number and street or rural route)
2
3
Single
Married
2014
Your social security number
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. a
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . a 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date a
a
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2014)
Employee:
State . . . . . . . . . . . . . . .
M
O V I E TE M
EN U E
AT E
RT
BE
AM
EN
L
SV
I
B
T OF
EV
ID
M
T
City. . . . . . . . . . . . . . . . . . . . . . .
AC
Print home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PL
Social Security no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PE TI T
Print full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SACHUSET
AS
TS
Rev. 1/12
EN SE
MASSACHUSETTS EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE
D E PA R
FORM
M-4
R
Zip . . . . . . . . . . . . . . . .
HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS
File this form or Form W-4 with
your employer. Otherwise,
Massachusetts Income Taxes
will be withheld from your
wages without exemptions.
2. If married and if exemption for spouse is allowed, write the figure “4.” If your spouse is age 65 or over or will
be before next year and if otherwise qualified, write “5.” See Instruction C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........
Employer:
3. Write the number of your qualified dependents. See Instruction D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........
Keep this certificate with your
records. If the employee is
believed to have claimed
excessive exemptions, the
Massachusetts Department
of Revenue should be so
advised.
1. Your personal exemption. Write the figure “1.” If you are age 65 or over or will be before next year, write “2” . . . . . . .
........
4. Add the number of exemptions which you have claimed above and write the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Additional withholding per pay period under agreement with employer $ _____________________
A.
Check if you will file as head of household on your tax return.
B.
Check if you are blind.
D.
Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income
will not exceed $8,000.
C.
Check if spouse is blind and not subject to withholding.
EMPLOYER: DO NOT withhold if Box D is checked.
I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Date. . . . . . . . . . . . . . . . . . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THIS FORM MAY BE REPRODUCED
THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE
A. Number. If you claim more than the correct number of exemptions, civil
and criminal penalties may be imposed. You may claim a smaller number of
exemptions. If you do not file a certificate, your employer must withhold on
the basis of no exemptions.
If you expect to owe more income tax than will be withheld, you may either
claim a smaller number of exemptions or enter into an agreement with your
employer to have additional amounts withheld.
You should claim the total number of exemptions to which you are entitled to
prevent excessive overwithholding, unless you have a significant amount of
other income.
If you work for more than one employer at the same time, you must
not claim any exemptions with employers other than your principal
employer.
If you are married and if your spouse is subject to withholding, each may
claim a personal exemption.
B. Changes. You may file a new certificate at any time if the number of
exemptions increases. You must file a new certificate within 10 days if the
number of exemptions previously claimed by you decreases. For example,
if during the year your dependent son’s income indicates that you will not
provide over half of his support for the year, you must file a new certificate.
C. Spouse. If your spouse is not working or if she or he is working but not
claiming the personal exemption or the age 65 or over exemption, generally you may claim those exemptions in line 2. However, if you are planning to
file separate annual tax returns, you should not claim withholding exemptions for your spouse or for any dependents that will not be claimed on your
annual tax return.
If claiming a wife or husband, write “4” in line 2. Using “4” is the withholding
system adjustment for the $4,400 exemption for a spouse.
D. Dependent(s). You may claim an exemption in line 3 for each individual
who qualifies as a dependent under the Federal Income Tax Law. In addition,
if one or more of your dependents will be under age 12 at year end, add “1”
to your dependents total for line 3.
You are not allowed to claim “federal withholding deductions and
adjustments” under the Massachusetts withholding system.
If you have income not subject to withholding, you are urged to have
additional amounts withheld to cover your tax liability on such income.
See line 5.
IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME
AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.
CONFIDENTIALITY STATEMENT
In keeping with Emerson Hospital policies it is the responsibility of all Emerson personnel, included but not limited to,
employees, medical staff and other health care professionals, volunteers, agency, temporary and registry personnel;
trainees, students and interns, and Emerson Practice Associates employees, to preserve and protect confidential patient,
employee and business information whether in hard copy, file, oral or computerized form. HIPAA and Massachusetts Law
establish protections to preserve the confidentiality of various medical and personal information and specify that such
information may not be disclosed except as authorized by law or the patient or individual.
Protected Health Information (PHI) is defined as any individually identifiable information in possession or derived from a
provider of health care regarding a patient’s medical history, mental or physical condition or treatment, as well as the
patients and/or their family members’ records, test results, conversations, research records and financial information.
I understand and acknowledge that:
1.
Unauthorized access, use or disclosure is strictly prohibited. Access to all patient, employee, financial and
proprietary information without specific written authorization, is permitted only when required for patient care or to
perform regular duties for the Hospital and only in accordance with this Agreement.
2.
Access to patient information by physician office staff is restricted to patients directly under the care of the
physician or physician group in which they are employed.
3.
All of Emerson Hospital’s information technology resources (including computers, telephones, telecopiers, email, Internet access and all other electronic devices and systems) are property of Emerson Hospital.
4.
Emerson’s Information Technology Resources contain various types of activity-monitoring capabilities that
document and monitor user activities, and that periodic audits are performed.
5.
It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records,
proprietary information and other confidential information relating to Emerson Hospital.
6.
I will discuss confidential information only in the work place as appropriate, and only for job related purposes,
and to refrain from discussing this information outside of the work place or within the hearing of other people who
do not have a need to know this information.
7.
I will only access or disseminate patient care information in the performance of my assigned duties and where
required by or permitted by law, and in a manner which is consistent with Emerson Hospital policies.
8.
Each time I access protected health information I will only use the minimum necessary required to do that
function of my job.
9.
All non-Emerson owned systems used in accessing PHI remotely must meet Emerson’s minimum IS security
recommendations and standards. No PHI will be download to portable media unless encrypted.
10. I will access information/documents needed to perform my job only through Citrix; no paper documents of any
kind shall be removed from the hospital.
11. I will avoid using personal telephones to contact patients unless approved by IS Security.
12. Unauthorized release of confidential information may make me subject to legal action and/or disciplinary action.
13. The law specially protects psychiatric and substance abuse records, any and all references to HIV testing,
positive or negative, and that unauthorized release of such information may make me subject to disciplinary
and/or legal action.
14. I am not to share my log-in user ID and/or password with anyone, and that any access to Emerson systems
made under my log-in/user ID and password is my responsibility.
All individuals must read and sign this form prior to the beginning of their assignment, issuance of a password(s), and
yearly thereafter.
Acknowledgment: I have read and understand the above Confidentiality Statement and I agree to comply with it. I understand that a
violation of any part of the Confidentiality Statement may result in disciplinary action up to and including termination of employment or, for
individuals who are not employed by the Hospital, termination of access to the Hospital’s information systems and/or facilities.
______________________________________
Print Name
___________________
Date of Hire/Transfer
_________________________________________
Mother’s Maiden Name (for security verification purposes)
_________________________
Position/Title
______________________________________
Signature
__________________________________
Department/Physician Practice
__________________________________________
Date
Agreement Form Approved: 05/2006; revised 01/2012; 05/2012; 12/2012; 07/2013; 09/2013; 11/2013; 01/2014;
05/2014
Page 1 of 2
erson Hospital
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SUBSTANCE-ABUSE-PREVENTION POLICY
I.
Basis of the Policy
Emerson Hospital ("the Company") is committed to protecting the safety, health, and
well-being of its employees, clients, and all people who come into contact with its employees,
workplaces, and property, and/or use its services. The Company recognizes that drug and alcohol
abuse pose a direct and significant threat to this goal, and to the goal of a productive and efficient
working environment in which all employees have an opportunity to reach their full potential.
The Company therefore is committed to ensuring a substance-abuse-free working environment
for all of its employees, and underscores that commitment through implementation and
enforcement of this Substance-Abuse-Prevention Policy ("Policy").
II.
Scope and Applicability
This Policy applies to all employees, including all management employees, and — as
appropriate and relevant — to all job applicants.
III.
Drug and Alcohol Prohibitions
(A)
Drug Abuse
Emerson strictly prohibits the possession, use, sale, attempted sale, purchase,
attempted purchase, conveyance, distribution, transfer, dispensation, cultivation, and/or
manufacture of illicit drugs or other intoxicants at any time, and in any amount or any
manner — as well as the abuse/misuse of alcohol and prescription drugs.
"Illicit drugs" includes all drugs, narcotics, and intoxicants for which possession or
misuse is illegal under federal law, and includes prescription medications for which the
individual does not have a valid prescription. The deliberate use of prescription medications
and/or over-the-counter drugs in a manner inconsistent with dosing directions, and in a manner
which may result in impairment, is considered illicit drug use. In addition, the use of chemical
intoxicants for other than a legitimate and therapeutic purpose is considered illicit drug use.
(B)
Alcohol Abuse and Misuse
Emerson recognizes the enormity and severity of the alcohol-abuse problem in American
society and in American workplaces. The Company therefore prohibits the abuse, misuse, or
possession of alcohol while working, present on the Company's premises (defined as all
buildings, facilities, and property — including parking areas — owned or leased by the Company,
and all places where the Company conducts business, including client facilities), or representing
the Company at any time and in any way.
-2-
The Company also prohibits the use of alcohol, or the possession of opened containers of
alcohol, by employees operating Company-provided vehicles, or operating any other vehicle
while on Company business. Moreover, the use or abuse of alcohol off-the-job which could
impair, to any extent, performance on-the-job, will be considered a violation of this Policy.
Notwithstanding the foregoing, the Company's executives may occasionally authorize
alcoholic beverages at approved Company functions at designated sites. In those situations, an
employee may consume a moderate amount of alcohol, provided that the employee's conduct
and demeanor remain business-like and professional at all times, and provided further that the
employee does not thereafter drive or otherwise engage in any activity which could be hazardous
if the alcohol consumed impaired or affected the employee's ability to perform those activities,
and does not otherwise engage in conduct which would reflect detrimentally on the Company.
(C)
Use of Prescription Medications
Employees who use prescription and/or over-the-counter medications — that the employee
or his or her health-care provider believes may impair the employee's ability to perform his or
her job responsibilities safely — are responsible for notifying their immediate supervisor or the
Human Resources Department so that steps can be taken to minimize the safety risks posed by
such use. Employees may be asked to obtain a doctor's certification that the employee can
safely perform the responsibilities of his or her position. Any information the Company may
learn about an employee's health or medicines will be treated as confidential, and will be shared
with Company personnel only on a need-to-know basis.
IV.
Discipline
Employees in violation of this Policy will be subject to disciplinary action, up to and
including termination, including for a first offense. Employees who are drug tested, and
whose drug tests are confirmed positive, will have their employment with the Company
terminated. Job applicants who test positive will be denied employment. In circumstances
which warrant it, the Company also will notify law enforcement, and will fully cooperate
with any resulting investigation and prosecution.
V.
Employee Assistance
The Company strongly encourages employees who believe that they have a problem with
alcohol or drugs — legal or illegal — to seek assistance before a violation of this Policy is found.
For those employees who self-identify a substance-abuse problem to the Company, sources of
help may be provided. The employee would be referred for a medical assessment, possible
counseling and rehabilitation, and possible re-testing during and after rehabilitation, and would —
at the Company's sole discretion -- be subject to continued employment.
-3VI.
Drug and Alcohol Testing
(A)
Job Applicants
All job applicants must take and pass a mandatory drug test as soon as practical following
their acceptance of a conditional offer of employment, and prior to the actual time they
commence employment with the Company. A confirmed positive test will result in the
withdrawal of an offer of employment. A job applicant's refusal to submit to testing, failure to
fully cooperate in the testing process, and/or attempt to tamper with, substitute for, adulterate,
dilute, or otherwise falsify a test sample will be considered a withdrawal from the application
process, and will result in denial of employment.
(B)
Employees
Employees may be subject to drug and/or alcohol testing as a condition of continued
employment as directed by the Company, at its sole discretion. This includes, but is not limited
to, drug and/or alcohol testing: (1) on a for-cause basis; (2) as part of a post-incident
investigation; (3) during and post-rehabilitation, including return-to-duty testing; (4) as
contractually required by the government or clients and/or (5) as otherwise deemed necessary
and appropriate by the Company.
An employee's refusal to submit to testing; failure to fully cooperate in the testing
process; attempt to tamper with, substitute for, adulterate, dilute, or otherwise falsify a test
sample; and/or any other conduct which would intentionally prevent or compromise a valid test
result will be considered insubordination and will result in termination of employment.
VII.
Consequences of a Positive Test
Any employee whose drug test is positive will be considered to be in violation of this
Policy, and will have his or her employment terminated.
VIII. Notification of Conviction
Consistent with the requirements of the Drug-Free Workplace Act of 1988, the
Company's employees working on federal government contracts must notify the Human
Resources Department of any criminal drug statute conviction for a violation occurring in the
workplace no later than five days after such conviction.
IX.
Searches
When Emerson has any reason to believe that an employee is violating any aspect of this
Policy, he or she may be asked by the Company to submit immediately to a search or inspection.
Such a search or inspection can be required at any time (including during breaks and meal
periods) while on Company premises, representing the Company, or at worksites where the
Company conducts operations.
-4This includes a search of an employee's person and/or the requirement that the employee
make his or her desk, work station, storage locker, briefcase, purse, pockets, wallet, personal
belongings, vehicles, accommodations, and/or any other property that he or she uses, has access
to, and/or has control of, available for inspection.
Any property provided by the Company, or its customers, to an employee is provided
with only a temporary license of use and/or access, and then only relative to the appropriate
performance of the employee's work responsibilities. Such license is specifically subject to the
condition that the employee must, on request, grant access to the property for inspection and
search. The Company reserves and retains the right to remove any lock or other devise securing
the property, as necessary and/or appropriate.
Entry on to the Company's premises or worksites constitutes a consent to searches and
inspections.
An employee's refusal to consent to a search or inspection when requested by Emerson
constitutes a violation of this Policy and — as with other violations of this Policy — is grounds for
adverse employment action, up to and including termination of employment.
X.
General Responsibility
Substance-abuse prevention is everyone's responsibility. The Company expects all of its
employees to recognize and accept this responsibility, and to do their part in assuring that —
working together — we can achieve and maintain a substance-abuse-free working environment
for all Emerson employees.
Attachment: Attachment A — Emerson Hospital Employee Acknowledgement Form
Attachment A
Emerson Hospital
Premium Care. Pelsorm
7.
Employee Acknowledgement Form
I hereby certify that Emerson Hospital has provided me with a copy of its SubstanceAbuse-Prevention Policy; that I have read and do understand the Policy; and that I agree to fully
comply with the terms and conditions of the Policy.
Date
Employee Signature
Employee Printed Name
Date
Witness Signature
Witness Printed Name
4816-7779-9185, v. 1
This Employer
Participates in E-Verify
This employer will provide the Social Security Administration
In order to determine whether Form I-9 documentation is valid,
(SSA) and, if necessary, the Department of Homeland Security
this employer uses E-Verify’s photo screening tool to match
(DHS), with information from each new
employee’s Form I-9 to confirm work
authorization.
IMPORTANT: If the Government cannot
confirm that you are authorized to work,
this employer is required to provide you
written instructions and an opportunity
to contact SSA and/or DHS before taking
adverse action against you, including
the photograph appearing on some
N O T I C E:
permanent resident and employment
Federal law requires
all employers
to verify the identity and
employment eligibility
of all persons hired to work
in the United States.
Citizenship and Immigration Services’
terminating your employment.
authorization cards with the official U.S.
(USCIS) photograph.
If you believe that your employer has
violated its responsibilities under this
program or has discriminated against
you
during
the
verification
process
based upon your national origin or
citizenship status, please call the Office of Special Counsel at
Employers may not use E-Verify to pre-screen job applicants or
to re-verify current employees and may not limit or influence the
choice of documents presented for use on the Form I-9.
For more information on E-Verify,
please contact DHS at:
1-888-464-4218
1-800-255-7688 (TDD: 1-800-237-2515).
If you have a legal right to
work in the United States,
there are laws to protect
you against discrimination
in the workplace.
In most cases employers
cannot require you to be a
U.S. citizen or permanent
resident or refuse any
legally acceptable
documents.
No employer can deny you
a job or fire you because
of your national origin or
citizenship status.
You should know that –
If any of these things have
happened to you, you may
have a valid charge of
discrimination that can be
filed with the OSC. Contact
the OSC for assistance in
your own language.
Or write to:
U.S. Department of Justice
Office of Special Counsel - NYA
950 Pennsylvania Ave., N.W.
Washington, DC 20530
In the Washington, D.C.,
area, please call
202-616-5594, TDD
202-616-5525
Call 1-800-255-7688. TDD
for the hearing impaired is
1-800-237-2515.
Office of Special Counsel for
Immigration-Related Unfair
Employment Practices
U.S. Department of Justice
Civil Rights Division
IF YOU HAVE THE RIGHT TO WORK,
Don’t let anyone take it away.
Emerson Hosp
Acknowledgement of Receipt of
E-verify Informational Posters:
English & Spanish
Notice of E-Verify Participation
Right to Work Poster
IPXOtillAVOIPE.RUMITIO WORK";
Donttafailioner . tiate *away . '
I hereby acknowledge that I have received a copy of the posters
shown above.
Employee Signature
Date:
Parking Form
Application Type:
Access Card
Today’s Date:
Access Badge #:
(6 digit number on the back of the card)
PERMIT HOLDER CONTACT INFORMATION
First name:
Last name:
Department:
Position:
Mr.
Mrs.
Ms.
Dr.
Contact Phone #:
Email Address:
Status:
Full Time
Part Time
Daily Physician
Other: ____________________
Work Schedule:
(Please circle
am or pm)
MON ________am/pm to________ am/pm
SAT________ am/pm to ________am/pm
TUES________am/pm to ________ am/pm
SUN________am/pm to________ am/pm
WED________am/pm to________ am/pm
*Variable _______am/pm to______am/pm
THU________am/pm to________ am/pm
*Describe Variable Here:
FRI_________am/pm to________ am/pm
VEHICLE INFORMATION
Vehicle:
Make
Model
Color
Plate #
Reg. State
#1:
#2:
Desired
Location:
Garage ($15 per month)*
Garage Lower Level ($25 per month)*
* Once Garage or Garage Lower Level access has been granted, you will receive notice by email. The parking cost will be deducted
directly from payroll. This cost is $3.47/week for Garage and $5.78/week for Garage Lower Level. By signing below I understand
and authorize payroll to process the transactions.
Signature:__________________________________
Date:____________________
I certify that the statements made on this application are true and I will notify the parking department whenever a change occurs in
the information given in this application. I also am aware that any falsification could result in the loss of all parking privileges,
individual or carpool. I also understand that any parking permit issued to me is a license to park my vehicle in the designated lot at my
own risk. That my use of the parking permit will not constitute Emerson Hospital or Curbside, Inc. as bailee of my vehicle or its
contents and that neither Emerson Hospital nor Curbside, Inc. nor any of its employees will be responsible for theft or damage to my
vehicle or its contents while in any Emerson Hospital and Curbside, Inc. parking facility. I understand that while Emerson Hospital may
provide some supervision and surveillance of some of the lots there will be times when any lot or portions thereof are not supervised.
Signature:__________________________________
Date: ____________________
Please email this completed form to [email protected] or submit to parking office.
Emerson Hospital
133 Old Road to Nine Acre Corner
Concord, MA 01742
(978) 369-1400
www. emersonhospital.org
Dear New Employee:
The attached policies reflect information that we are responsible for providing to new employees.
The information is important for you to read and, as your employment with us proceeds, you will
be asked to learn other policies and procedures that relate to your employment with Emerson
Hospital.
As mandated by the Massachusetts Board of Registration in Medicine, health care facilities are
required to give written instructions on their incident reporting system and their Patient's Rights
Policy to all new employees involved in patient care.
We are providing you these written instructions, as they must be received within five days of
employment. You will then receive an education and training session during your orientation
program that will assist you in understanding these policies and your responsibilities.
Feel free to contact Patient Care Assessment, extension 3095, if you have any questions
regarding the attached policies 1-4.
In addition, we are providing you with a copy of our Harassment/Sexual Harassment policy and
our Code of Organizational Behavior and Ethics policy which can also be found on the hospital
intranet. You will also receive an overview of Human Resources policies in your orientation
packet. Anytime you have questions regarding Human Resources, please call us at extension
3070.
Please sign below that you have received the policies and information listed. This
acknowledgement will be placed in your personnel file.
I have received copies of the following policies:
1. Code Of Conduct
2. Report of Occurrence/Report of Medication Related Occurrences.
3. Patient and Family Complaints.
4, Patient's Rights and Responsibilities and written notice given to all patients.
5. Devise-Related Incidents: Compliance with the Safe Medical Device Act.
6. Harassment/Sexual Harassment
7. Ethical Concerns
8. Code of Organizational Behavior and Ethics
Employee Signature
Date
AUTHORIZATION FOR DIRECT DEPOSIT OF PAY
NAME:______________________________________________EMPLOYEE ID# ________________EXT:___________
FUNDS MAY BE DIRECTLY DEPOSITED INTO MORE THAN ONE ACCOUNT
ONLY FILL OUT THE SECTION(S) THAT APPLY
EMPLOYEES WHO CHOOSE DIRECT DEPOSIT WILL NOT RECEIVE A PAPER COPY
THEY WILL RECEIVE A COPY ELECTRONICALLY THROUGH THEIR EMERSON OUTLOOK EMAIL ACCOUNT
****YOU MUST ATTACH A VOIDED CHECK IN ORDER TO PROCESS THIS FORM****
BANK NAME
BANK NAME
BANK NAME
TRANSIT
NUMBER
NEW DIRECT DEPOSIT:
ACCOUNT
NUMBER
ACCOUNT TYPE
DEPOSIT AMOUNT
(CHECKING OR SAVINGS)
(FIXED AMT OR NET PAY)
CHANGE EXISTING DIRECT DEPOSIT TO THE FOLLOWING:
TRANSIT
ACCOUNT
ACCOUNT TYPE
NUMBER
NUMBER
(CHECKING OR SAVINGS)
(FIXED AMT OR NET PAY)
CANCEL THE FOLLOWING DIRECT DEPOSIT:
TRANSIT
ACCOUNT
ACCOUNT TYPE
NUMBER
NUMBER
(CHECKING OR SAVINGS)
(FIXED AMT OR NET PAY)
DEPOSIT AMOUNT
DEPOSIT AMOUNT
ALL CHANGES, EXCEPT FOR DOLLAR AMOUNTS WILL GENERATE A LIVE CHECK (RED) FOR TWO WEEKS.
Direct deposits are processed through the New England Automated Clearing House (NEACH) System. The deposits are normally
processed by the NEACH system on Wednesdays. Credits to your accounts will appear 24 to 48 hours after the deposit is processed.
DURING HOLIDAY WEEKS, DEPOSITS MAY BE DELAYED.
IF YOUR DIRECT DEPOSIT REJECTS DUE TO INACCURATE INFORMATION ON THIS FORM, IT WILL
AUTOMATICALLY BE CANCELLED AND YOU WILL CONTINUE TO RECEIVE A LIVE CHECK UNTIL THE
CORRECT INFORMATION IS RECEIVED.
I hereby authorize my employer to have my pay directly deposited according to the above information.
EMPLOYEE SIGNATURE:________________________________________________ DATE:__________________