Our Values and Ethics at Work Acknowledgement Form

1. I acknowledge that I have received a copy of Catholic Health Initiatives’ Our Values and Ethics at Work Reference Guide and I have read it or agree to read it completely. I also agree to discuss any questions or concerns regarding this reference guide with my supervisor or other appropriate Catholic Health Initiatives’ leader.*

I AGREE

I DO NOT AGREE

2. I agree to comply with the Our Values and Ethics at Work Reference Guide standards and guidelines and any other standards or policies set by Catholic Health Initiatives or the local organization I serve that apply to me in my role throughout my association with Catholic Health Initiatives. I understand that it is my responsibility to report any concerns regarding possible violations of these standards, guidelines and/or policies. I also understand that I may be asked to cooperate in an investigation of matters that may affect or relate to compliance with applicable standards, guidelines or policies and agree to do so when asked. Furthermore, I understand that neither Catholic Health Initiatives nor the local organization I serve will retaliate against me for making a report in good faith.*

I AGREE AND UNDERSTAND

I DO NOT AGREE AND UNDERSTAND

3. I understand that Catholic Health Initiatives and/or its organizations will conduct an excluded provider background check prior to my employment or association and periodically thereafter. I understand that Catholic Health Initiatives reserves the right to terminate my employment or other association if I am an excluded provider.*

I UNDERSTAND

I DO NOT UNDERSTAND

4. I understand that the Our Values and Ethics at Work Reference Guide contains standards for behavior within Catholic Health Initiatives and its organizations and is not a contract for employment or other services. I also understand that these standards may be amended, modified or clarified at any time, and that I will receive periodic updates to these guidelines.*

I UNDERSTAND

I DO NOT UNDERSTAND

Date *

Name *

First Name *

Last Name *

Email *

Last 4 digits of Your Social Security Number *

I will be volunteering at: *

5. I understand that by responding and submitting an answer to any of the questions above I am consenting to provide my Acknowledgement and Certification of the applicable statement(s) by electronic signature. I understand that by responding and submitting an answer to any of these questions it is the equivalent of actually "signing" my name to the statement(s) that precede(s) it. My electronic signature will constitute my "original" signature as well as my Acknowledgement and Certification of the applicable statement(s) when used or printed. I understand that I may access a copy of the "Our Values and Ethics at Work Reference Guide" by going to the CHI Web site. I understand that I may also choose to print a copy of this Employee Acknowledgement and Certification and/or this Notice of Electronic Signature now by pressing CTRL- P on my keyboard. A signed copy of this Employee Acknowledgement and Certification will be maintained in my volunteer file and I can receive a copy at any time from my Volunteer Services office.*

I UNDERSTAND

I DO NOT UNDERSTAND