F-QM-HR-004-A-V0 — Employee 201 Personnel File, Immunization & Occupational Health Record
Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.
Parent document: LAB-QM-HR-004 — Personnel Records and Occupational Health Policy (parent is encoded in the form number)
Rendered in-browser from the project's Word file F-QM-HR-004-A-V0-employee-personnel-file-201-checklist-and-index.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.
| Document # | F-QM-HR-004-A-V0 | Parent Document | LAB-QM-HR-004 — Personnel Records Management Policy |
|---|
---
Part 1 — Employee Identification & Staff Category
| Field | Detail | Field | Detail |
|---|---|---|---|
| Employee Full Name: | Employee ID No.: | ||
| Date of Hire / Entry: | YYYY-MM-DD | Employment Status: | [ ] Job Order (JO) [ ] Regular/Plantilla [ ] Contractual |
| Designation: | [ ] Chief Medical Technologist / LQM / [ ] Medical Technologist / [ ] Laboratory Aide | PRC License No. (if RMT): | |
| Mobile Phone: | Emergency Contact: |
---
Part 2 — Mandatory Credentials & Dossier Contents Checklist
2.1 Medical Technologists (Technical Staff)
| Credential / Document Required | Present in File? | Verified Details & Expiration Date | Verifier Initials |
|---|---|---|---|
| 1. Official Appointment / Job Order Contract | [ ] Yes [ ] No | Contract Term: YYYY-MM-DD to YYYY-MM-DD | |
| 2. PRC Professional License Card (Authenticated Copy) | [ ] Yes [ ] No | PRC Reg No.: _________ Valid Thru: YYYY-MM-DD | |
| 3. PRC Board Examination Certificate / Rating | [ ] Yes [ ] No | Board Examination Rating: ________ % | |
| 4. BS Medical Technology / Medical Lab Science Diploma | [ ] Yes [ ] No | College / University: ________________________ | |
| 5. Official Transcript of Records (TOR) | [ ] Yes [ ] No | Graduation Date: YYYY-MM-DD | |
| 6. Updated Curriculum Vitae / Resume | [ ] Yes [ ] No | Verified by Chief MT Date: YYYY-MM-DD | |
| 7. Initial Orientation Checklist (F-QM-HR-001-A-V0) | [ ] Yes [ ] No | Onboarding Completed: YYYY-MM-DD | |
| 8. Annual Competency Assessment Record (F-QM-HR-002-A-V0) | [ ] Yes [ ] No | Most Recent Assessment: YYYY-MM-DD | |
| 9. Continuing Professional Development (CPD) Certificates | [ ] Yes [ ] No | Cumulative Units Verified |
2.2 Laboratory Aides (Non-Technical Ancillary Support Staff)
| Credential / Document Required | Present in File? | Verified Details & Expiration Date | Verifier Initials |
|---|---|---|---|
| 1. Official Appointment / Job Order Contract | [ ] Yes [ ] No | Contract Term: YYYY-MM-DD to YYYY-MM-DD | |
| 2. High School Diploma or Vocational Health Certificate | [ ] Yes [ ] No | Institution: ____________________________ | |
| 3. General Facility & Laboratory Orientation (F-QM-HR-001-A-V0) | [ ] Yes [ ] No | Completed Date: YYYY-MM-DD | |
| 4. Biosafety, PPE & Chemical Safety Orientation | [ ] Yes [ ] No | Verified by Biosafety Officer: YYYY-MM-DD | |
| 5. Non-Technical Core Competency Checklist | [ ] Yes [ ] No | Evaluated by Chief MT: YYYY-MM-DD |
Notice: Under DOH A.O. 2021-0037 and hospital quality policies, Laboratory Aides are non-technical support staff. They shall never perform clinical examinations, operate primary analyzers, or validate or release laboratory results.
---
Part 3 — Immunization & Occupational Health Surveillance Record
| Health Surveillance Component | Date Administered / Cleared | Facility / Provider | Result / Verification Summary | Status |
|---|---|---|---|---|
| Hepatitis B Vaccine — Dose 1 | YYYY-MM-DD | Batch / Lot No.: ______________ | [ ] Complete | |
| Hepatitis B Vaccine — Dose 2 | YYYY-MM-DD | Batch / Lot No.: ______________ | [ ] Complete | |
| Hepatitis B Vaccine — Dose 3 | YYYY-MM-DD | Batch / Lot No.: ______________ | [ ] Complete | |
| Post-Vaccination Anti-HBs Titer | YYYY-MM-DD | Titer Level: _______ mIU/mL | [ ] Immune (≥10 mIU/mL) | |
| Annual Influenza Immunization | YYYY-MM-DD | Formulation Year: 2026-2027 | [ ] Current | |
| Annual Medical Physical Examination | YYYY-MM-DD | Fit for duty clearance issued | [ ] Cleared | |
| Routine Chest Radiography (X-Ray) | YYYY-MM-DD | Findings: Normal / Non-cavitary | [ ] Cleared |
Staff Declination (if applicable): Staff who decline vaccination for documented personal/medical reasons sign a formal declination waiver in the presence of the Hospital Director.
---
Part 4 — Job Description & Authority Scope Acknowledgment
I acknowledge that I have received, reviewed, and understand my approved Position Description (F-QM-HR-003-A-V0), which specifies my duties, reporting relationships, performance expectations, and ethical obligations.
Staff Signature: ________________________________________ Date: ____________________ Printed Name: ________________________________________ Designation: [ ] RMT [ ] Lab Aide
---
Part 5 — Annual Currency Audit & Dossier Custody
The Chief Medical Technologist / Laboratory Quality Manager conducts this audit annually in the first quarter to check that licenses are valid, competency records are current, and health clearances are up to date.
| Audit Year | All Required Documents Intact? | PRC License Verified Active? | Annual Competency Verified? | Health Clearance Current? | Audited by (CMT Signature) | Date |
|---|---|---|---|---|---|---|
| 2026 | [ ] Yes [ ] Incomplete | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | [ ] Yes [ ] Pending | ||
| 2027 | [ ] Yes [ ] Incomplete | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | [ ] Yes [ ] Pending | ||
| 2028 | [ ] Yes [ ] Incomplete | [ ] Yes [ ] NA | [ ] Yes [ ] Pending | [ ] Yes [ ] Pending |