HRCHC Respirator Agreement
Usage and Responsibility
As part of our infection control enhancement, respirators are provided to certain clinical staff. The respirators are provided by Hampton Roads Community Health Center and remain the property of HRCHC. These items are for use while working at the center.
In order to receive a respirator, you must complete training on how to use a respirator along with a quiz.
You must also be fit tested for the respirator. This is currently performed at our facility and involves a medical evaluation form and clearance.
Please acknowledge the items below as well as the replacement cost for each item by initialing next to each line item in the chart below.
Usage and Responsibility
As part of our infection control enhancement, respirators are provided to certain clinical staff. The respirators are provided by Hampton Roads Community Health Center and remain the property of HRCHC. These items are for use while working at the center.
In order to receive a respirator, you must complete training on how to use a respirator along with a quiz.
You must also be fit tested for the respirator. This is currently performed at our facility and involves a medical evaluation form and clearance.
Please acknowledge the items below as well as the replacement cost for each item by initialing next to each line item in the chart below.
Replacement of Items
In the event of a lost, destroyed or damaged respirator over and beyond normal use, the employee is responsible for the cost of replacement. The cost to replace the item is $66.02 and will be deducted through payroll deduction. The Company will then replace the missing item, subject to the availability of the order.
Return of Items
Upon separation of employment the following terms apply:
All items issued are considered HRCHC property and must be returned in good and usable condition no later than my last day of employment. If the issued items are not returned upon separation of employment or the items are returned damaged and unusable, the cost of replacing these items will be withheld from my final paycheck.
I understand the above Agreement and agree to abide by the indicated terms. Should I fail to return any items listed upon employment separation from HRCHC, my signature authorizes the organization to deduct the replacement cost of such items from my final pay check.
I agree these items were obtained on my behalf, by HRCHC, as a means to elevate infection control in the work environment.
In the event of a lost, destroyed or damaged respirator over and beyond normal use, the employee is responsible for the cost of replacement. The cost to replace the item is $66.02 and will be deducted through payroll deduction. The Company will then replace the missing item, subject to the availability of the order.
Return of Items
Upon separation of employment the following terms apply:
All items issued are considered HRCHC property and must be returned in good and usable condition no later than my last day of employment. If the issued items are not returned upon separation of employment or the items are returned damaged and unusable, the cost of replacing these items will be withheld from my final paycheck.
I understand the above Agreement and agree to abide by the indicated terms. Should I fail to return any items listed upon employment separation from HRCHC, my signature authorizes the organization to deduct the replacement cost of such items from my final pay check.
I agree these items were obtained on my behalf, by HRCHC, as a means to elevate infection control in the work environment.
