DAVID GEFFEN SCHOOL OF MEDICINE
CHECKLIST FOR NEW HIRES, REHIRES, AND TRANSFERS INTO DEPARTMENT
EDB Personnel/Benefits/Payroll/Administrative Related Process
EMPLOYEE NAME: / Employee ID#:ACTION: New Hire Rehire Transfer into Department
Date of Action: / Livescan/Background Check
Completed Date:
Appointment: Career Limited Casual/Restricted Work-Study / Contract Per Diem
New Employee Orientation Health System & DGSOM Clinical Staff DGSOM ½ day N/A Scheduled Date: ______
Items to include in personnel file prior to completing new hire/rehire/transfer Forms:
*if applicable –
Copy to Employee & Personnel File – Rev
Online employment application/Resume
Hire Approval or EDB Action Request Form
New Hire Form to Staffing (to close Requisition)
Offer/Welcome Letter
Personnel File and Verification of Vacation/Sick balances (if campus/department transfer)*
Source Verification of Professional Licenses on CA.gov websites*
Copy of Professional Licenses*
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
Forms to be signed by employee for personnel file & distribute to Office of Record if Required:
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
Personal Data Form and Emergency Contact Form
Demographic Data Transmittal Form
State Oath & Patent
Authorization to Work (I-9)
W-4
Payroll Wage Disposition Request (Surepay)
UCRS 419 Statement-Employment Not Covered by Social Security*
Confidentiality Statement
Abuse Reporting (Elder, Child, and Domestic)*
Code of Conduct Employee Signature Page (employee keeps handbook)
Designation of Physician Form (employee keeps Facts about Workers Compensation section)
Magnet Program Certification Educational Data Collection Sheet*
World Class Practices: My Commitment to Care
Job Description (signed and placed in personnel file)
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
Benefits Information / Administrative Forms & Items to provide to employee:
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
Your Group Insurance Plans Booklet w/ Medical Benefits Summary and Calculation Rate Charts
“Always At Your Service” pamphlet
UPAY 850 (rehires and change in status enrollments only)*
Benefit Enrollment PIE (PIE date:______)
Family Status Changes Benefits Checklist
Summary Plan Description for Health and DepCare FSA, UCRP, 403(B) and 457(B)
Who’s Your Beneficiary? (flyer)
Department Policy/Standards/Work Rules/Staff Rights Policy (for Patient Care Employees)
IDOC (New Hire/Rehire/Transfer summary)
Photo ID Application (color: ______)
Keys to Office (Key number/room number: ____/____)
OTR Manual/Training (Dept rep to add employee in OTR and assign supervisor)*
Overtime/Comp time Election*
EH&S/Hazardous Materials Training*
Parking Authorization for Payroll Deductions
(permit type/lot assigned: ______/______)*
“Getting a UCLA Log on ID” handout for Learning Management System access (Ethics, Sexual Harassment)
Notify DSA/Information Systems and provide Email access (email address: ______)
Phone set up/pager/cell phone/Blackberry*
UCLA Database Directory (update needed)
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
Employee Required Online Training: Must complete within 30 days of hire
HIPAA Education and Training Program (http://hr.healthcare.ucla.edu/hipaa2/main.asp)
C-ICARE Annual Online Training (http://hr.healthcare.ucla.edu/training/CICARE/index.htm)
Code of Conduct Training and Quiz (http://www.mednet.ucla.edu/ComplianceQuiz/)
Other Employee Required Training:
Compliance Briefing: UC Ethical Values and Conduct (http://lms.ucla.edu)
Sexual Harassment Prevention Training for Supervisors (http://lms.ucla.edu)
I acknowledge that the items checked above were provided to me. I agree to complete all Employee Required Online Training within 30 days from my hire date and turn in printed training certificates to my Department Representative.
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
______
Employee Signature / Date
______
Department Representative Signature / Date
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010
*If Applicable
Copy to Employee and Personnel File –Rev. 9/2010