VA Assignment of Functional Categories Form
This form is used for the classification of employees based on their level of access to Individually Identifiable Health Information (IIHI) and Protected Health Information (PHI). It is applicable upon hiring, annually, or as needed due to job changes. The supervisor and employee discuss the level of access required for performing assigned duties.
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How do I fill this out?
To fill this form out, start by entering the employee's name and job title. Then, the supervisor must check off the appropriate functional category and obtain the necessary signatures. Ensure to maintain a copy in the Supervisor's Personnel Files.
How to fill out the VA Assignment of Functional Categories Form?
1
Enter the employee's name and job title.
2
Supervisor checks off the appropriate functional category.
3
Both employee and supervisor sign the form.
4
Maintain a copy in the Supervisor's Personnel Files.
5
Complete the process upon hiring, annually, or as needed due to job changes.
Who needs the VA Assignment of Functional Categories Form?
1
Direct Care Providers need this form to classify their level of access to health information.
2
Indirect Care Providers use this form to specify their access in support of treatment duties.
3
Administrative Staff engage with this form for oversight functions and data verification.
4
Health Information Support Services Staff utilize this form for assigning and accessing medical records.
5
Quality Oversight and Investigations personnel leverage this form for compliance and review tasks.
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What are the instructions for submitting this form?
To submit the VA Assignment of Functional Categories Form, contact your immediate supervisor to review and complete the necessary information. Obtain signatures from both the employee and supervisor. Maintain a copy of the form in the Supervisor's Personnel Files. For digital submissions, enter the form details using PrintFriendly's PDF editor and save the completed document. Contact the IT helpdesk if you encounter any technical issues.
What is the purpose of this form?
The purpose of the VA Assignment of Functional Categories Form is to classify employees based on their level of access to Individually Identifiable Health Information (IIHI) and Protected Health Information (PHI). This ensures that all employees have the required access to perform their assigned duties effectively. The classification helps in maintaining confidentiality, ensuring compliance, and improving the efficiency of health information management.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Name: The name of the employee who is being classified.
- 2. Department/Service Assigned: The specific department or service where the employee is assigned.
- 3. Job Title: The official job title of the employee.
- 4. Immediate Supervisor: Supervisor's name and responsibilities for reviewing and signing the form.
- 5. Functional Categories: Check off the appropriate functional category that matches the employee's role.
- 6. Type of Protected Health Information Accessible: Specify the level of access to health information granted to the employee.
- 7. Allowable Systems of Records Notice (SORN) for Limited Access: Identify the specific systems of records the employee can access.
- 8. Primary Conditions for Access to Information: Conditions under which the employee can access the specified health information.
What happens if I fail to submit this form?
Failure to submit the VA Assignment of Functional Categories Form can lead to non-compliance and potential issues with access control management.
- Access Issues: Employees may not have the appropriate access to perform their duties, impacting productivity and care delivery.
- Non-Compliance: The organization may face compliance issues for not properly assigning access levels as required.
- Security Risks: There is a heightened risk of data breaches or unauthorized access to sensitive health information.
- Documentation Gaps: Lack of proper record-keeping and documentation for employee access levels can lead to audit and legal issues.
How do I know when to use this form?
- 1. Upon Hiring: Complete the form as part of the employee onboarding process.
- 2. Annual Review: Review and update the form annually to ensure accurate classification.
- 3. Job Changes: Update the form if there are changes in the employee's job role or responsibilities.
- 4. Compliance Audits: Utilize the form during compliance audits to verify access control.
- 5. Department Transfers: Submit a new form if an employee transfers to a different department or service.
Frequently Asked Question
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Access the form by visiting PrintFriendly and uploading the PDF file.
Can I edit the form online?
Yes, you can edit the form online using PrintFriendly’s PDF editor.
How do I sign the form?
Sign the form digitally using the signature tool provided on PrintFriendly.
Can I share the completed form?
Yes, you can share the completed form via email or download it and share it manually.
What information do I need to fill out the form?
You need employee’s name, job title, functional category, and necessary signatures.
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You can save the form after editing using PrintFriendly’s save feature.
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Yes, you can download the edited form directly from PrintFriendly.
How do I fill out the functional categories?
Check off the applicable functional category based on the employee's role and duties.
How do I maintain a copy of the form?
Maintain a copy of the form in the Supervisor's Personnel Files after completion.
Can I use the form for multiple employees?
Each form is specific to an individual employee and must be filled out separately for each one.
