AAAHC Life Safety Code (LSC)Surveyorpart-Time Employee Application

AAAHC Life Safety Code (LSC)SurveyorPart-time Employee Application

It is the policy of this organization to provide equal opportunity to all employees and applicants without discrimination based on race, color, sex, national origin, religion, marital status, disability, Vietnam veteran status, age, sexual orientation or other conditions specified in Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Vietnam Era Veterans Readjustment Assistance Act of 1974.

Instructions

Please type or legibly print your responses. If more space is needed, please attach additional sheets and reference the question being answered.
To type your answers, place your cursor on the gray boxes and type as much text as necessary. Click on the gray outlined boxes for check-marked answers.Use the Tab key to move to the next field.
If a question is not applicable to you, please respond with N/A.
Incomplete applications cannot be processed and will delay the process.

Submit your application to Julie Haugh, Assistant Director, Surveyor Services, as follows:

By Mail: 5250 Old Orchard Road, Suite 200, Skokie, IL 60077
Fax: 847-324-7716
Email:

AAAHC’s phone number is 847-853-6060.

Please submit current copies of the following documents, where applicable, with this application.Please make and/or maintain a copy of the documents you submit. Please use the following as a checklist.

Required of all applicants:
Completed application, including signature pages
Current curriculum vitae or resume or, as applicable, a complete job history;
A written statement describing why you would like to become a surveyor for AAAHC
How did you hear about this opportunity to become a surveyor?

Surveyor Requirements

LSC Surveyors are required tobe available to conduct a minimum of 12 surveysannually,comprising approximately two days per survey including travel.
Surveys are conducted around the country and, in most cases, travel is required.
Applicants should have a laptop computer, regular access to an email program and access to the internet.

Identifying information

Today’s date:
First name: / Middle: / Last name:
Nickname:

Home information(Thiswill be used as your primary contact information unless otherwise specified.)

Address:
City: / State: / Zip:
County: / Home phone: / Cell phone:
Home fax: / Home email:

Nearest airport:

If you are not a U.S. citizen, do you have authorization to work in the U.S.? Yes No N/A

If no, please explain:

If you are currently employedby an accredited ambulatory health care organization, please indicate the accrediting organization(s):

Not Applicable AAAHC JCAHO Other:

Employment History

Begin with your most recent/present employer and list all work experience in order. Please include all full-time, part-time and temporary positions.

Is your current employment (select all that apply):

With an ambulatory health care facility?

With an organization that owns, operates and/or manages ambulatory health care facilities?

With an organization that provides consulting services to ambulatory health care facilities?

Not related to ambulatory health care?

Other – please explain:

Question does not apply to me because I am fully retired from practice, employment or military service.

Employer name:
From (month/year): / To (month/year):
Your title: / Full time Part Time Temporary
Telephone: / May we contact: Yes No
Employer address:
Describe how this experience contributes to your overall knowledge of the Life Safety Code requirements and their application:
Employer name:
From (month/year): / To (month/year):
Your title: / Full time Part Time Temporary
Telephone: / May we contact: Yes No
Employer address:
Describe how this experience contributes to your overall knowledge of the Life Safety Code requirements and their application:
Employer name:
From (month/year): / To (month/year):
Your title: / Full time Part Time Temporary
Telephone: / May we contact: Yes No
Employer address:
Describe how this experience contributes to your overall knowledge of the Life Safety Code requirements and their application:
Employer name:
From (month/year): / To (month/year):
Your title: / Full time Part Time Temporary
Telephone: / May we contact: Yes No
Employer address:
Describe how this experience contributes to your overall knowledge of the Life Safety Code requirements and their application:

Please check your current and any additional organization types with which you have experience, and provide supporting comments.

Facility Type / Check setting(s) in which you have experience or expertise. / Provide supporting comments below for each area checked.
Medicare Certified/Deemed ASCs (3+ ORs)
Medicare Certified/Deemed ASCs (1-3 ORs)
Hospitals
Office based settings (non-surgical)
Other:

Which of the following best describes your involvement with fee-for-service consulting activities (check all that apply)? Fee-for-service is defined as consulting that results in a customer paying you directly for your services (if self-employed) or paying your employer for your services (if employed by a consulting organization).

I am not involved with fee-for-service consulting of any sort

I am self-employed as a consultant on a full-time basis

I am self-employed as a consultant on a part-time basis

I provide consulting services through my full-time employment with an organization that provides
consulting services

I provide consulting services through my part-time employment with an organization that provides
consulting services

Other – please describe:

If you are involved with fee-for-service consulting activities, are any of your consulting activities related to helping organization prepare for accreditation?

Question does not apply because I am not involved with fee-for-service consulting activities

Yes – please describe these consulting activities:

Licensure: Check here if not applicable:

License number: / State: / Issue date: / Expiration date:
State: / Issue date: / Expiration date:
Agency Awarding Licensure

Other credentials/affiliations: (Please list)

Education

Graduate and/orprofessional

Institution name:
City: / State: / Degree awarded:
Start date (month/year): / Completion date (month/year):

Undergraduate

Institution name:
City: / State: / Degree awarded:
Start date (month/year): / Completion date (month/year):

Other education/ training

Institution name:
City: / State: / Certificate awarded:
Start date (month/year): / Completion date (month/year):

References

Name three peer references who have current knowledge of your work abilities, ethical character, and ability to work cooperatively with others.Please complete all contact information.

Reference 1

Name: / Credential(s):
Phone: / Fax: / Email:
Address: / City: / State: / Zip:

Reference 2

Name: / Credential(s):
Phone: / Fax: / Email:
Address: / City: / State: / Zip:

Reference 3

Name: / Credential(s):
Phone: / Fax: / Email:
Address: / City: / State: / Zip:

Survey and travel information

Indicate any day(s) of the week on which you are NOT available to perform surveys

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you have any limitations that may impact flexibility in travel, i.e., prefer not to fly, distance limitations, etc.? Please be aware that surveys are scheduled throughout the U.S. and generally require a commitment of two to three days (including travel and conducting the survey).

Yes No If yes, please explain:

Please indicate any issues you feel may impact your ability to perform surveys:

Confidential Information

Please answer Yes, No or N/A for all questions. If you answer Yes to any of the questions, please provide an explanation in the space below, and include any additional documentation.

Are you eligible for employment in the United States? Proof of citizenship or immigration status will be required upon employment.

/ Yes / No / NA

Have you ever been convicted of a criminal offense or do you have any criminal charges pending other than for minor traffic violations?

/ Yes / No / NA

Are you related, biologically or by legal action, to any employee of this organization? If yes, please state name and relationship:______

/ Yes / No / NA

Have you ever applied for a position at this organization before? If yes, please state date applied and position: ______

/ Yes / No / NA

Have you ever worked at this organization before? If yes, please state dates of employment and previous title:______Why did you leave this organization?______

/ Yes / No / NA

Have you ever been known by a different name? If so, please indicate:______

/ Yes / No / NA

Are you able to perform the essential surveyor functions with or without a reasonable accommodation? (Please describe below any accommodation required.)

/ Yes / No / NA

If you answered yes to any of these questions, please provide an explanation below or attach a detailed explanation.

Release

I would like to conduct surveys for the AAAHC. I acknowledge that should my application be accepted, I will be required to be available for all required training activities and a minimum of one (1) survey every month. In addition, I understand that for any Medicare Deemed Status survey that I perform, AAAHC must permit a surveyor to serve as witness if the Centers for Medicare & Medicaid Services (CMS) takes an adverse action based on accreditation findings of this survey (42 C.F.R. 488.4(b)(3)(v)), and I, therefore, agree to serve as said witness, upon request of AAAHC or CMS.

I hereby certify that the information provided on this application is complete and accurate. I agree to notify AAAHC of any changes. I authorize AAAHC and its agent to pursue and secure any additional information pertaining to the verification of information provided in this application.

We requireyour signature.

Name: / Date: / Signature:

AAAHC Surveyor Confidentiality and Conflict of Interest Policy

As a surveyor employee and representative of AAAHC, I understand my first and foremost priority when conducting surveys on behalf of AAAHC is to be an ambassador of AAAHC, an objective fact finder, a reporter of personal observations, as well as an educator and consultant when appropriate.

In fulfilling this role, I understand that the sole reason I am sent on a survey is to conduct AAAHC business in a professional manner with integrity and objectivity. Further, it is understood that I remain a representative for AAAHC with the understanding that under no circumstances may I solicit personal business, or take part in any activities which appear to be in furtherance of any of my own personal, entrepreneurial endeavors. Surveyors are not to discuss any consulting activities with anyone connected to a survey until the accreditation decision for that survey has been rendered. It is also understood that all information, including but not limited to, non-public information submitted on a confidential basis by parties seeking accreditation, schedule lists for future site visits, survey reports, reports of the internal proceedings and deliberations of AAAHC’s standing and ad hoc committees, interviews, reports, statements, memoranda and other data used in the course of business are to remain strictly confidential and will not be disclosed to any other party. To maintain the confidentiality of survey reports, surveyors are not permitted to allow non-surveyors, or surveyors not assigned to a particular survey, to enter findings from that survey into SurveyLink or other survey documents such as worksheets.

If I am selected by AAAHC to become a surveyor, I acknowledge that by virtue of my relationship with AAAHC I may obtain or come into contact with the confidential and proprietary methodologies and techniques (“Confidential Information”) of AAAHC, of AAAHC subsidiaries, and of AAAHC affiliates, including any program operated or managed by AAAHC or a AAAHC subsidiary or affiliate, I agree (i) that during the course of my relationship with AAAHC, I shall not conduct nor perform any activity on behalf of, nor enter into any arrangement or agreement with, any other accreditation organization or any other entity conducting activities competitive with the activities of AAAHC, AAAHC subsidiaries, AAAHC affiliates, or any program operated or managed by AAAHC or a AAAHC subsidiary or affiliate (such accreditation organization or entity conducting competitive activities is referred to herein as a “Competitor”); (ii) not to disclose at any time any portion of such Confidential Information, either directly or indirectly, to any Competitor or other third party, including that I may not serve as an expert witness with regard to any aspect of the AAAHC, including but not limited to standards, surveyors and survey processes; and (iii) that AAAHC may declare me ineligible to conduct surveys, or continue to act as a surveyor, on behalf of AAAHC because of my relationship with any Competitor, and that such determination is based upon AAAHC’s interest in protecting its legitimate business interests.

I agree, in good faith:

To refrain from any activities during the conduct of an AAAHC survey that may be construed as solicitation.
That I will not undertake any consultative business for personal profit, with any organization for which I have conducted an accreditation survey, for a period of three years following that survey unless the consultative activity is scheduled or approved by the AAAHC.
That for a period of six years after acting as an independent consultant to an organization, I will not perform an accreditation survey of that organization.
To refer all questions from organizations that I survey regarding consultants and consultative services to the AAAHC.

I also understand that AAAHC policy and practice warrants that surveyors decline from participating in any surveys of organizations which may be in direct competition with the surveyors’ business interests, or which bear any significant beneficial interest to the surveyor or any member of the surveyor’s immediate family. Further, I agree to disclose to AAAHC any personal relationships I have with known current or recent past (within three years) staff of organizations that I am volunteering to survey or am asked to survey, so that AAAHC may determine if a conflict of interest exists. If I learn of any type of potential conflict after accepting a survey assignment, I agree to disclose the potential conflict to AAAHC as soon as I am aware of it.

I have read this statement in its entirety, and I agree to all provisions described herein.

We require your signature.

Name: / Date: / Signature:

Equal Opportunity/Affirmative Action Information

The information requested below is voluntary and will be kept confidential.

Date: / First and Last Name:
Check one: Male Female
Check one: White
Black or African American
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian/Pacific Islander
Two or more races
Check if any of the following applies to you: Vietnam Era Veteran Disabled Veteran
Referral Source – check any of the following that may apply to you:
Newspaper or newsletter advertisement or article
Surveyor referral
AAAHC website
Other (please specify):
Applicant Signature:

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