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OLA Agreements - Profile Acknowledgement, HIPAA, State Disclosures

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    By submitting this application, I certify and attest that the information provided is true and correct to the best of my knowledge. I understand that submitting false or misleading information may disqualify me from employment, that submitting this application does not create an employment contract, and that any employment that follows will be at-will such that my employment would be subject to termination at any time with or without notice or cause.

    Profile acknowledgement
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    Kentucky - REGARDING EMPLOYMENT IN KENTUCKY: FOR THIS TYPE OF EMPLOYMENT STATE LAW REQUIRES A CRIMINAL RECORD CHECK AS A CONDITION OF EMPLOYMENT. - It is company policy that for employment in KY, in accordance with KRS 216.789, the company is prohibited against referring an employee to a nursing facility if that person has been convicted of a felony offense related to theft: abuse or sale of illegal drugs: abuse, neglect, or exploitation of an adult: sexual crime. - Per KRS 216.724, this contract does not restrict your employment opportunities, including contract buy-out provisions or non-compete clauses; nor will you be charged a fee should you be hired by the health care facility to which you are assigned.

    State disclosures
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    With the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), personally identifiable healthcare records came under a new and heightened level of confidentiality. In the regular course of business, the family of brands owned and operated by Ingenovis Health, Inc., including Trustaff, Fastaff, U.S. Nursing, Healthcare Support, Springboard Health, Vista Staffing Solutions, and VitalSolution brands, and their subsidiaries and affiliates (collectively, the “Company” or “we” or “our”) interacts and communicates directly with candidates who may share their personally identifiable information. In turn, we collect, store and process the information electronically and/or manually. With the belief that it is a person's right to have their personal information kept private, the Company conducts business with respect for and in compliance with all applicable health information privacy laws, including but not limited to HIPAA. We respect our legal obligation to implement privacy procedures and technical security measures to keep your personal information private and secure. As we are obligated to give you notice of our privacy practices, the statement of policies and protocols which follows describes how our staff may use and disclose your medical information and how you may get access to this information and relative accounting. For the purpose of this document and for employment through any of the Company’s brands, your “health information” includes the following items that we request on behalf of our facility clients: * Annual physician’s statement * Documentation used to prove immunity to measles, mumps, and rubella \[laboratory titers or records of MMR injection(s)\] * Documentation used to prove immunity to varicella \[laboratory titer, record of Varivax immunization, or immune by declination\] * Documentation used to prove immunity to HBV \[laboratory titer or record of HBV immunization series\] or a declination statement thereof * Annual tuberculosis screening \[PPD test results or chest x-ray reading\] * Pre-employment drug screening \[conducted by the Company\] Generally, we cannot use your health information or disclose it outside of our office without your written permission. The written permission comes from your completed consent form. We ask you to sign the consent form allowing us to use and disclose your health information for purposes of submittal to client facilities, of assignment to job openings at client facilities, and continued employment through any of the Company’s brands at client facilities. For example, your health information may be sent via fax or email to a client representative either for submittal consideration or to confirm placement. Facility representatives \[HR managers, nursing officers, or unit managers\] will review your health information to evaluate whether or not you meet their standard immunization requirements set forth for temporary staff. A Company representative will advise you of any necessary medical documentation for placement. Any variation from the facility standard may delay or cancel an assignment. We may refuse to place you if you do not sign the consent form. At times, client facilities may request further documentation than the above defined “health information” of a candidate’s health and immunization records to comply with state or local regulations. At those instances, a Company representative will advise you of the requirements and request your consent for that additional information. The law gives you many rights regarding your health information. You may request photocopies of your health information, an amendment to any incorrect or incomplete information, additional copies of this notice, or a list of the disclosures we have made of your health information. The Company reserves the right to change this statement at any time in compliance with and as allowed by law. If we make any changes, the new policies and protocols will apply to your health information that we already have as well as to such information that we may generate or request in the future. We will send out notices of any changes via mail and post them in our office and on our website ([http://www.ingenovishealth.com](http://www.ingenovishealth.com/)). If you should have any questions concerning the Company’s privacy practices or wish to access or correct private information collected from you, please contact our HIPAA Privacy Officer via mail, phone, fax, or email: MAIL: 9997 Carver Road, Suite 300 Cincinnati, OH 45242 PHONE: 877-880-0346 FAX: 888-897-9197 EMAIL: [privacy@trustaff.com](mailto:privacy@trustaff.com) By my signature below, I confirm that I have read, understand, and consent to the policies and protocols regarding disclosure and transmission of information as outlined in this statement regarding my health information.

    HIPAA confidentiality & privacy statement
  • Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 04/30/2026 Why are you being asked to complete this form? We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years. Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you have a disability? A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to: - Alcohol or other substance use disorder (not currently using drugs illegally) - Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS - Blind or low vision - Cancer (past or present) - Cardiovascular or heart disease - Celiac disease - Cerebral palsy - Deaf or serious difficulty hearing - Diabetes - Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders - Epilepsy or other seizure disorder - Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome - Intellectual or developmental disability - Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD - Missing limbs or partially missing limbs - Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports - Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS) - Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities - Partial or complete paralysis (any cause) - Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema - Short stature (dwarfism) - Traumatic brain injury PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

    Voluntary Disclosures