"Outside Employment Policy Statement - Adult Care Food Program" - Florida

This "Outside Employment Policy Statement - Adult Care Food Program" is a document issued by the Florida Department of Elder Affairs specifically for Florida residents with its latest version released on August 3, 2016.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Florida Department of Elder Affairs.

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Download "Outside Employment Policy Statement - Adult Care Food Program" - Florida

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ADULT CARE FOOD PROGRAM
OUTSIDE EMPLOYMENT POLICY STATEMENT
Name of Institution: ______________________________________________________
Contract Number: __________________
All Adult Care Food Program (ACFP) Institutions of multiple facilities must provide a policy on outside
employment. The policy must restrict other employment by employees that interferes with an employee’s
ACFP responsibilities/duties, including outside employment that constitutes a real or apparent conflict of
interest. Other ethical and conflict of interest issues may also be addressed. (A sample of a possible
outside employment policy is provided for your reference. The sample may be used in part or in its
entirety to assist in development of the institution’s policy)
Each institution of multiple centers is required to annually submit a blank copy of their policy
statement with this certification. The statement will be kept on file with the Adult Care Food Program.
I certify that a policy is in effect as of ___________________________ (date of implementation) and
that the institution’s employees have been made aware of it.
_______________________________________________
___________________
Signature of the Chairman of the Board, President, Owner Date Or Delegated
Authority
ATTACH A COPY OF THE INSTITUTION’S OUTSIDE EMPLOYMENT POLICY
Rev. 8/3/2016
ADULT CARE FOOD PROGRAM
OUTSIDE EMPLOYMENT POLICY STATEMENT
Name of Institution: ______________________________________________________
Contract Number: __________________
All Adult Care Food Program (ACFP) Institutions of multiple facilities must provide a policy on outside
employment. The policy must restrict other employment by employees that interferes with an employee’s
ACFP responsibilities/duties, including outside employment that constitutes a real or apparent conflict of
interest. Other ethical and conflict of interest issues may also be addressed. (A sample of a possible
outside employment policy is provided for your reference. The sample may be used in part or in its
entirety to assist in development of the institution’s policy)
Each institution of multiple centers is required to annually submit a blank copy of their policy
statement with this certification. The statement will be kept on file with the Adult Care Food Program.
I certify that a policy is in effect as of ___________________________ (date of implementation) and
that the institution’s employees have been made aware of it.
_______________________________________________
___________________
Signature of the Chairman of the Board, President, Owner Date Or Delegated
Authority
ATTACH A COPY OF THE INSTITUTION’S OUTSIDE EMPLOYMENT POLICY
Rev. 8/3/2016
_______________________________________
(Institution’s Name)
OUTSIDE EMPLOYMENT POLICY
&
DISCLOSURE FORM
S A M P L E
All employees are expected to avoid activities, which create a conflict of interest with their
responsibility to this institution. The institution also expects its employees to observe the highest moral
and ethical standards in any dealings in which they represent the institution.
The institution recognizes and respects each employee’s right to privacy and to engage in personal
activities outside the scope of his or her employment with the institution. Each employee also has
an obligation, however, to refrain from activities which conflict with the institution’s operation.
The institution reserves the right to determine when an activity conflicts with its interest and to
take whatever action is necessary up to and including termination of employment.
Any of the following may be considered a conflict and therefore must be disclosed by the employee in
an effort to resolve the potential conflict. Potential conflict of interest includes: outside employment,
provision of services for competitors or clients, outside business interest, accepting gifts from
companies/suppliers/individuals doing business with the institution, and promoting personal business on
institution’s property during business hours or institution employment.
Employees are required to report and disclose any of these or other areas, which may constitute a
conflict of interest. Please list all other employment or businesses in which you are involved.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
This is to certify that I have read and understand this policy and have disclosed outside employment or
business(s) in which I am involved. I further understand if at any time I become involved in any outside
employment or business, I must report it to this institution within ______ days.
________________________________________
_____________________
Signature of Employee
Date
Rev. 8/3/2016
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