Document Downloads & Binding Arbitration Information

STAFF DISCLOSURE

Statement of Knowledge

I understand that (INSERT NAME OF PRACTICE) requires a commitment to honesty and that one of my roles in this office is to help achieve that. In order for management to be aware of departures from office policy, I willingly report the following for the past twelve months:

Sexual Harassment

 

            I have not seen an instance of sexual harassment either by the doctors or staff members. I agree to immediately report all such instances. I understand that patients who exhibit improper behavior are to be promptly dealt with by doctors and/or management.

OSHA

 

            I have been trained in OSHA procedures and know of no instance where (INSERT NAME OF PRACTICE) has failed to provide materials and staff for OSHA compliance. I agree to report such instances of staff failures, knowing management will deal with these.

Illegal Acts

 

            I know of no instance of illegal acts being performed by staff members. I agree to report such instances should I observe their occurrence.

Drug Abusive Practices

 

            I know of no instance where drugs have been abused by staff members. I know of no instances where prescriptions have been written for non-dental needs. I agree to report all such instances to management.

            Management has informed me that I may report rules violations not only to management but also to any state authority having jurisdiction in those matters.

________________________________________________
Printed Name

________________________________________________ Date________________
Signed

________________________________________________ Date________________
Witnessed

Subscribed and sworn to me this _____ day of ____________________, 20 _______

________________________________________________________, Notary Public