Pre-Employment Checklist Pre-Employment Checklist Samaritan Services Inc. Pre-Employment Checklist Name * Title * CERTIFICATION Licence * Expiration Date * Licence Registration * Expiration Date * CPR * Expiration Date * ACLS * Expiration Date * IV Certification * Expiration Date * Other Certification * Expiration Date * I9 DOCUMENTATION * SS Card Picture ID/Driver License Passport Green Card Work Authorization BACKGROUND CHECK * Criminal Background OIG Exclusions License Verification (NJ) References (3) Passport Size Photo (For ID) LIABILITY INSURANCE:Expiration Date ***Coverage in the amount of $1-6 Million for RN & LPN’s REGISTRATION PACKAGE * Application Background Check Auth. Drug Screen Auth. Welcome Package Completion of Samaritan Orientation Module and Video Employment Agreement Employment Agency Contract (DOCA) W4 Clinical Skills Checklist Annual In-Service/Core Competency Completion of Facility Orientation Module Date Completed Rate Given Expiration Date Date Completed ANNUAL PHYSICALExpiration Date * Checkboxes * PPD1 PPD2 OR Chest X-Ray Rubella (German Measles) Rubeola (Measles) Varicella Hepatitis Vaccine I II III Flu Shot Drug Screening If NO Hepatitis provide our declination form Comments Submit