Legal Questionnaire

Have you ever:

(this includes any offense where you were found guilty, plead guilty or plead nolo contendere (no contest). You may omit: a conviction of misdemeanor while under the age of 18, if the records were sealed under the Penal code 1203.45b. Any conviction specified in Health and Safety code section 11361.5 which pertains to various marijuana offenses (a conviction will not necessarily disqualify you from consideration for employment).

My signature certifies that all information contained within my application is correct and maybe verified by Global Healthcare Agency, LLC in compliance with the Virginia Law. It also acknowledges that I am aware that it is my responsibility to review and policy and procedure documents of each hospital/facility in which I work, prior to beginning my initial shift.

I have reviewed the applicant's qualifications and skills that qualify for the position.

Do Not Send Prevention: Quiz

TERMINATION SCALE ACKNOWLEDGEMENT

Do Not Sends

The Following point system is used to determine termination as a result of Do Not Sends.

1Point

• Attitude / lack of professionalism / customer service

2 Points

• Clinical Incompetence – poor clinical performance
• Poor time management
• Medication Error
• Documentation Deficiencies Lack of Compassion

3 Points

• Danger to patient.
• No call, No Show.
• Departing facility before end of shift secondary to dissatisfaction with assignment.
• Do Not Send from any Travel Assignment regardless of origin.

5 Points

• Illegal Behavior (Includes false identity; falsified documentation, use of or distribution of controlled substances etc.)
• PT. abandonment. When nurse is under investigation for above behavior they will be considered terminated until exonerated from all accusations.
• Error resulting in Pt. Death or Permanent physical or mental damage.
• Self-terminating travel assignment without proper notice to facility or Staffing Agency.

A nurse who receives 5 points will be considered for termination. Any nurse involved in illegal activity will be terminated immediately.

I have read and understand the Termination Scale Policy of Global Healthcare Agency, LLC in particular the Section entitled “Do Not Send policy and Process.”

Employee Handbook Acknowledgement Form

I acknowledge that I have received a copy of G lobal Healthcare Agency, L L C, Inc. Employee Handbook. I acknowledge that I have been informed that the complete Global Healthcare Agency, LLC. employee handbook is available at www.globalhealthcareagencyllc.com

I understand that in processing my application with Global Healthcare Agency, LLC. an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless Global Healthcare Agency, LLC. from any liability. I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or Interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment if employed. I further authorize Global Healthcare Agency, LLC. to check my credit and conviction records, as needed, on a continuous basis as it relates to my employment. I am granting Global Healthcare Agency, LLC. authorization to release confidential medical Information upon the request from Global Healthcare Agency, LLC. clients while I am actively working at the client’s facility and /or during the profiling and placement processes.

I understand that Global Healthcare Agency, LLC's goal is to always provide me with a consistent level of service. If for any reason I am dissatisfied with Global Healthcare Agency, LLC.' service or the service provided by one of Global Healthcare Agency, LLC. Clients, I am encouraged to contact the local manager to discuss the issue. Global Healthcare Agency, LLC. has processes in place to resolve customer complaints in an effective and efficient manner. If the resolution does not meet my expectation, I am encouraged to call the Global Healthcare Agency, LLC. corporate office at (571) 401-1933. A corporate representative will work with me to resolve my concern. I understand that any individual or organization that has a concerns about the quality and safety of patient care delivered by Global Healthcare Agency, LLC. healthcare professionals, which has not been addressed by Global Healthcare Agency, LLC. management, is encouraged to contact the Joint Commission at www.jointcommission.org or by calling the Office of Quality Monitoring at 630 792 5636. Global Healthcare Agency, LLC. demonstrates this commitment by taking no retaliatory or disciplinary action against employees when they do report safety or quality of care concerns to the Joint Commission.

I have read and understand the entire Global Healthcare Agency, LLC. policies and my requirements as a Global Healthcare Agency, LLC. employee In particular the Section entitled "Do Not Send policy and Process”. I understand that if I have any questions and/or need clarification for items addressed in the handbook, it is my responsibility to contact the Global Healthcare Agency, LLC. office to discuss.

Acknowledgement of Annual Education and Confidentiality of Patient Healthcare Information

I understand that the above mentioned materials provide guidelines and summary information about the company’s policies and procedures. I also understand that it is my responsibility to read, understand, become familiar with, and comply with the standards that have been established.

Authorization to Disclose information on Employment file, Background check, Medical Records and Drug Screening

By affixing my signature hereunder, I authorize G lobal Healthcare A gency, L L C . to release any and all confidential employment background check and medical information contained in my employment file to any medical facility or entity with which Global Healthcare A gency, L L C . has staffing agreement, and to any other governmental or regulatory agency such agency’s request. For all other purposes, Global Healthcare Agency, LLC, shall keep my employment confidential and shall advise any medical facility or other entity to which records have been provided to also keep such record confidential. I hereby hold G lobal Healthcare Agency, L L C . harmless for any result (s) that arises with regards to the release of this confidential information by G lobal Healthcare A gency, L L C . Medical records information is confidential and G lobal Healthcare A gency, L L C . will instruct client facilities and / or other entities to treat the provided information confidential as well.

I consent to a urine, blood or breath sample for the purpose of an alcohol drug, intoxicant or substance abuse screening test. Furthermore, I consent to the release of the results for purposes for determining the fitness of employment or continued employment.

I authorize Global Healthcare Agency, LLC. to contact past employers and references regarding my employment history. I hereby release all previous employers and references from any liability for furnishing this information in this application, reference information and medical information to G lobal Healthcare A gency, L L C. and any facilities I might be sent on assignment.

My signature hereunder further indicated that I have read and understood the Employee authorization to release confidential information on employment file, background check, medical records and drug screening.

I certify that the facts contained in this application are true and accurate. I authorize the employer to investigate any and all questions relating to this application. I release all parties from all liability, including but not limited to, the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.

Global Healthcare Agency, LLC. does not discriminate in respect to hiring, termination, compensations and all other terms and conditions of privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy or related medical conditions, marital status, religious creed or disability.

Hepatitis B Vaccine informed consent / waiver

Declination

I understand that due to my occupational exposure to blood and other potentially infectious materials. I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been informed and have the opportunity to ask questions and understand the benefits and risks of Hepatitis B vaccine. I understand that I must have three (3) doses of vaccine to confer immunity. However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effects from the vaccine. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B which is a serious disease.

HEPATITIS B

Is a viral infection caused by Hepatitis B virus (HBV) which causes death in 1-2% of patients. Most people with hepatitis B recover completely but approximately 5-10% becomes chronic carriers of the virus. Most of these people have no symptoms but can continue to transmit the disease to others. Some may develop chronic active hepatitis and cirrhosis. HBV also appears to be a causative factor in the development of live cancer. Thus, immunization against hepatitis can prevent acute hepatitis and also reduce sickness and death from chronic active hepatitis, cirrhosis and liver cancer.

VACCINE

The Hepatitis B vaccine is produced from the plasma of chronic HBV carriers. The vaccine consists of highly purified formalin-inactivated hepatitis B antigen (viral coating material). It has been extensively tested for safety in chimpanzees and three doses of vaccine achieve high levels of surface antibody. (anti-HBS) and protection against Hepatitis B. Persons with immune system abnormalities such as dialysis patients have less response to the vaccines but, over half of those receiving it do develop antibodies. Full immunization requires 3 doses of vaccine over 6 month’s period although; some persons may not develop immunity after 3 doses. There is no evidence that the vaccine has ever caused hepatitis B or AIDS. However, persons who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization. The duration of immunity is unknown at this time, but is probably long term.

POSSIBLE SIDE EFFECTS

The incidence of side effects is very low. No serious side effects have been reported with the vaccine. A few persons experienced tenderness and redness at the site injection. Low grade fever may occur. Rash, nausea, joint pain and mild fatigue have also been reported. The possibilities exist that more serious side effects may be identified in the future.

Attestation

I have already been vaccinated for Hepatitis B. I will be able to provide the proper documentation or record of my vaccination.

Vaccination Attestation Form

ANNUAL FLU VACCINE

H1N1 VACCINE

LATEX ALLERGY QUESTIONNAIRE

1. Please check the appropriate answer:

2. If you have ever worn latex gloves:

3. When you are wearing or around others that wearing latex gloves, have you noted any:

556 Garrisonville Road, Suite 202, Stafford, VA 22554 Tel: 571 401 1933 Fax: 571 401 1934 www.globalhealthcareagencyllc.com

TDAP Immunization Declination Form

I understand that my occupational exposure to patients, blood or other potentially infectious materials at healthcare facilities with the following vaccine preventable diseases puts me at risk of acquiring the disease. I have had the opportunity to be vaccinated, however, I choose to decline the vaccination(s) checked below at this time. I understand that by declining vaccine protection I continue to be at risk of acquiring the disease.

I understand that in the event of exposure, I may be requested to not visit healthcare facilities for at least the incubation period of the disease to which I have been exposed.

I acknowledge that each healthcare facility determines vaccination requirements, and that a vaccination declination may not satisfy these requirements.

Welcome to Global Healthcare Agency, LLC. Your employment at Global HealthcareAgency, LLC is at will and either party may terminate employment with or without cause. This agreement is not designed to be a contract or to alter the at‐will nature of the employment relationship. If you accept employment with Global Healthcare, you agree to abide by the Company’s rules and policies set forth in this agreement and in the employee manual.

1. I understand that I will be required to provide, in a timely manner, all necessary documentation, including but not limited to, my resume, licenses, certificates, physical report, drug screens, background checks etc. in order for me to be approved for any travel/per‐diem assignment with a Global Healthcare client. Failure to do so may result in termination of my employment with Global Healthcare.

2. I understand that as part of the above approval process, an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I hereby authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquiries or disclosure.

3. I understand that I am not in any obligation to accept an assignment offered by Global Healthcare. But once I accept a travel/per‐diem assignment, I pledge the following:
a. To cooperate with the Client’s reasonable instructions and accept the direction, supervision, and control of any and all responsible person(s) in the Client facility
b. To observe any relevant rules and regulations of the Client facility to which my attention has either been drawn or which I might reasonably be expected to ascertain
c. To not engage in any conduct detrimental to the interests of the Client
d. To honor my commitment to complete any assignment/shift that I have accepted. If I fail to complete any assignment/shift, I understand that I have voluntarily terminated my employment with Global Healthcare.

4. I understand that I am to contact my Global Healthcare representative immediately if I am experiencing any difficulty on my assignment/shift or if there are any changes in job description, location, or working hours by the Client.

5. I am to contact Global Healthcare immediately if it is impossible for me to report to work. Global Healthcare staffers are available 24/7, so you may call us any time of the day or night; however our normal office hours are 9:00 am to 5:00 pm, Monday to Friday. Please call us in enough time that we might schedule a replacement for your position. I understand that if I do not report to my assignment and/or do not call Global Healthcare, I have voluntarily terminatedmy employmentwithGlobal Healthcare. I understand that I must notify Global Healthcare beforehand if I am late for work or take time off, failing which I understand that I have voluntarily terminated my employment with Global Healthcare.

6. If I am confirmed for a shift and I cancel my availability for that shift later than 4 hours before the start of that shift, then I may be required to pay a late cancellation fee equivalent to 4 hours times the Client bill rate. The late cancellation penalty will be applied to my payroll by deducting the full amount from the next payroll cycle.

7. While on a temporary assignment, if the Client offers me a permanent position or if one is discussed, I will contact my Global Healthcare representative immediately. All fees and conditions are to be handled by Global Healthcare. It is unlikely that one of Global Healthcares’ Clients would ask me to work for them on my own rather than through Global Healthcare. I understand that if I go work directly for a Client within one year of my temporary assignment, I will be responsible for paying all employment fees or charges incurred.

8. I understand that Global Healthcare is committed to maintaining a safe working environment for all employees. If I am ever asked to do anything unsafe, observe unsafe working conditions, or am injured at work, I will contact Global Healthcare immediately. Furthermore, I agree to perform all work in as safe a manner as possible. If I experience an accident or injury while working for Global Healthcare, I will notify Global Healthcare within 24 hours of the incident.

9. I understand that all client and patient information supplied to me shall be held in strictest confidence, and all product and materials, including, but not limited to, patent records, client records, documentation, reports, charts, manuals, letters, programs and any and all other sources of information given to me or obtained by me from the client or at the work location will be returned to the Client at the completion of my shift/assignment. I also agree not to disclose any company trade secrets or confidential information of Global Healthcare or its Client to any other entities or individuals

10. Global Healthcare issues paychecks every other Monday for the hours worked in the preceding two weeks. I understand I am required to present to Global Healthcare, EVERY MONDAY, an actual timesheet signed by the Client in order to have my paycheck issued on Monday. If I fail to provide such time card in a prompt manner, I understand that it will result in my pay being carried over to the next pay period.

11. I understand that ALL overtime hours must be pre‐authorized by Global Healthcare. If I work overtime that is not pre‐ authorized, I accept and understand that I will not be paid for those hours. I further understand that all matters relating t o the Global Healthcare wages and rates are confidential and I will not discuss them with Clients, other employees of client or Global Healthcare, or any co‐worker at the work location, and in doing so, could result in my immediate dismissal from the assignment and possible termination from Global Healthcare

12. I understand that any monies due Global Healthcare resulting from loans, advances, damaged property, lost propertyincluding badges, or unauthorized use of property, including, but not limited to late shift cancellation penalties, the unauthorized or improper use of telephone, postage meters, computer equipment, software etc. at Global Healthcare or the Client, may be deducted from my paycheck(s).

13. When assigned to a contract or per‐diem assignment, I understand that within 24 hours from the last day of my assignment,I am required to confirm my availability for a new assignment.I understand that it must be in WRITING ONLY, by either email to staffing@globalhealthcareagencyllc.com OR fax to 571 401 1934 . I accept and understand that when I do not email or fax my availability within the specified time period, I am refusing further work with GlobalHealthcare and thereby voluntarily resigning from my employment with Global Healthcare. I understand that my unemployment benefits may be denied when I voluntarily resign my employment with any company.

14. I understand that the assignment is based on the agreement between Global Healthcare Staffing and the Client Facility. Client Facility has the right and privilege to cancel or modify the terms of the assignment with or without notice. I understand and accept that Global Healthcare will not be liable for any consequential damages, losses, expenses, inconveniences, or loss of alternative employment as a result of Client Facility’s changes to the assignment. I understand Global Healthcare Staffing will be obligated to pay only for the approved hours worked as indicated on a client‐approved timesheet

15. I understand and agree that in case of dispute or controversy arising from or relating to this Employment Agreement, the matter shall be referred for resolution to Global Healthcare, whose decision shall be final and binding on both parties

I acknowledge that before I signed the document, I was provided a copy for my review and was advised to seek legal counsel before signing this document.