Home Overview Getting Started Attachments Preparation Checklist In the Event of an Emergency
 

STEP ONE: Attachment A1

Attachment A1 - The Employee Information Form

Click to Open Attachment A1 *when prompted, SAVE attachment to your computer.

This form collects the information needed for your dispensing roster. On this form, the employee will indicate the name and number of persons for whom they will pick up medication. The persons listed can be those who are living in the same household as an emergency responder or the same household as the employee. Attachment A1 contains sensitive information and should be treated as a confidential record. Access to these documents should be limited. Attachment A1 is to be recollected promptly so that a dispensing roster can be created.

 Attachment A1: Distribution

 The distribution process should be determined by the creator of the database and your Human Resources department, and should be based on what works best for your agency.

Suggestions:

  • Distribute the form at an all-staff meeting
  • Email the form for the employee to print, include instructions
  • Distribute the form with employee paycheck
  • Distribute the form to supervisors, who would then distribute the form to their employees
  • Distribute the form to the employee’s mailbox
  • Add this form to your agency’s new employee packet

Attachment A1: Collection

Once the employee has filled out Attachment A1, the form will be recollected and returned to the creator of the database. Upon collection, all documents should be filed and stored as a back-up system to the Attachment A2: Dispensing Roster. Again, this process should be based on what works best for your agency.

Suggestions:

  • The form could be returned directly to the creator of the database.
  • The form could be collected by supervisors and then returned to the creator of the database.
  • The forms should be stored in a secure file system.

Attachment A1: Annual Reviews/Revisions

Attachment A1 should be reviewed at least annually. Revisions made to Attachment A1 must be recorded in Attachment A2: Dispensing Roster.  The process of reviewing the forms is to be determined by the creator of the database and Human Resources, and should be based on what works best for your agency.

Suggestions:

  • File Attachment A1: Employee Information Forms by department, so that forms can be returned to department/division supervisor, who then distributes the forms to the employee's mailbox for their review and revision.
  • Ask employees to review their Employee Information Sheet upon yearly distribution of W2 forms.

 

 
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