Exhibit A "Strike Contingency Plan" - Connecticut

What Is Exhibit A?

This is a legal form that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Connecticut State Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Exhibit A by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download Exhibit A "Strike Contingency Plan" - Connecticut

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Page 1 of 29
Rev. 11/7/08,
Reviewed 12/10, 1/15
EXHIBIT A
State of Connecticut
Department of Public Health
Strike Contingency Plan Requirements for Nursing Homes, Rest Homes, Residential Care Homes, Health Care Facilities for the
Handicapped, Residential Alcohol or Drug Treatment Facilities and Infirmaries in Educational Institutions
Section 19a-497-1(b) of the Regulations of Connecticut State Agencies
REGULATION
PRINT OR TYPE INFORMATION BELOW
(1) Name and address of the facility:
(1)
level(s) of care:
licensed capacity:
(2) Name of labor organization that has notified the facility of its
intention to strike;
(3) Date and time the strike is expected to occur;
(4) Categories and numbers of personnel expected to strike;
Example:
Registered Nurses:
Dietary Aides:
Name of Facility ___________________________________________________________________
Page 1 of 29
Rev. 11/7/08,
Reviewed 12/10, 1/15
EXHIBIT A
State of Connecticut
Department of Public Health
Strike Contingency Plan Requirements for Nursing Homes, Rest Homes, Residential Care Homes, Health Care Facilities for the
Handicapped, Residential Alcohol or Drug Treatment Facilities and Infirmaries in Educational Institutions
Section 19a-497-1(b) of the Regulations of Connecticut State Agencies
REGULATION
PRINT OR TYPE INFORMATION BELOW
(1) Name and address of the facility:
(1)
level(s) of care:
licensed capacity:
(2) Name of labor organization that has notified the facility of its
intention to strike;
(3) Date and time the strike is expected to occur;
(4) Categories and numbers of personnel expected to strike;
Example:
Registered Nurses:
Dietary Aides:
Name of Facility ___________________________________________________________________
Page 2 of 29
Strike Contingency Plan
Print or Type Plan in Spaces Provided Below
REGULATION
NAME(S)
ADDRESS(ES)
PHONE NUMBER(S)
(5) Names, addresses and
telephone numbers of
the following:
Facility owner(s)
Administrator
Medical Director
Medical Staff
Name of Facility ___________________________________________________________________
Page 3 of 29
Strike Contingency Plan
Print or Type Plan in Spaces Provided Below
REGULATION
NAME(S)
ADDRESS(ES)
PHONE NUMBER(S)
(5) Continued
Medical Staff
(cont.)
Director of Nurses
Assistant Director of
Nurses
Maintenance
Supervisor
Other(s)
Name of Facility ___________________________________________________________________
Page 4 of 29
Strike Contingency Plan
Print or Type Plan in Spaces Provided Below
REGULATION
NAME(S) (INCLUDE NAME OF CONTACT PERSON
EMERGENCY PHONE
AND ADDRESS WHENEVER POSSIBLE)
NUMBER
(6) Names, daytime and emergency
telephone numbers of the following:
(A) Local fire department;
(B) Local police department;
(C) Local director of health;
(D) Utility companies:
Gas
Water
Electricity
Telephone Co.
Other
(E) Ambulance services;
(F) Closest hospital able to
admit patients or clients
in case of an emergency;
Name of Facility ___________________________________________________________________
Page 5 of 29
Strike Contingency Plan
Print or Type Plan in Spaces Provided Below
REGULATION
NAME(S) (INCLUDE NAME OF CONTACT PERSON
EMERGENCY PHONE
AND ADDRESS WHENEVER POSSIBLE)
NUMBER
(6) continued
(G) All providers of basic services to the
facility:
oxygen services
emergency generator repair service,
fuel supplier,
electrical service,
plumbing service,
suppliers or vendors of food (e.g.
meats, vegetables, breads, milk,
ensure, etc.)
Name of Facility ___________________________________________________________________