Master Staffing Forms

Sick Leave

• Sick Leave form

Injury on the job

• Injury Incident Report forms

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Annual Training and Tests

• Mandatory Core Topics Training
• Mandatory Core Topics Test
• Mandatory Core Topics Renewal

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Annual Forms

• 2023 W4 and EDD
• 2023 National Patient Safety Goals
• Flu Declination(to be completed every fall season)
• Physical - If you do not have a recent physical, you may bring this form to a physician.
• Tuberculosis Exposure Questionnaire


• Age Skills Checklist
• RN Skills Checklist
• LVN Skills Checklist
• CNA Skills Checklist
• Caregiver Skills Checklist
• RT Skills Checklist


• CCU Skills Checklist
• DOU TELE Skills Checklist
• ER Skills Checklist
• GI Endoscopy Skills Checklist
• Maternal Child Skills Checklist
• Mental Health Skills Checklist
• MS Skills Checklist
• NICU Skills Checklist
• Nursery Skills Checklist
• OR Skills Checklist

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County Forms

• County - DHS Profile Checklist
• County - IT Request Form
• County - Annual DHS Joint Commission OSHA Attestation
• County 2022 - Health Forms (E2 Tuberculosis, K-NC, N-NC, P-NC)
• County 2022 - E2 Annual Health Questionnaire
• County 2022 - E2 Pre-placement Tuberculosis History
• County 2022 - K-NC
• County 2022 - N-NC
• County 2022 - P-NC
• County 2022 - 2023 Seasonal Influenza

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USC Hospital Forms

• USC - Meal and Rest Period Obligation Acknowledgment
• USC - First Meal Period Waiver
• USC - Second Meal Period Waiver
• USC 2022 - Temporary Worker Agreement Overview
• USC 2022 - Timekeeping Memo
• USC 2022 - Harassment and Discrimination Pamphlet for all Temp Staff
• USC 2022 - Contract RN Education Competency Validation Summary
• USC 2022 - Registry Packet

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San Dimas Community Hospital Form

• SDCH - RN Float Registry Expectations