North Carolina Division of State Operated Healthcare Facilities (DSOHF)

**The forms in this section are required for all NC DHHS DSOHF Facilities**

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*Agency Staff Expectations  Adobe Sign PDF
*Interview Questions for Contract Registered Nurse or Licensed Practical Nurse   Adobe Sign PDF
*Interview Questions for Contract Health Care Technician   Adobe Sign PDF
*DHHS Criminal Record Check Consent Form and Release of Information   Adobe Sign PDF
*Medical Clearance Form for Contract Nursing Service Provider Personnel  (PDF Only) PDF

North Carolina Department of Revenue

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NC-4 EZ Employee’s Withholding Allowance Certificate (Short Form)    Adobe Sign PDF
NC-4 Employee’s Withholding Allowance Certificate (Long Form)    Adobe Sign PDF

North Carolina Department of Public Safety (Corrections)

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Candidate Nursing Requirements  (PDF Only) PDF

Broughton Hospital – Morganton, NC

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Broughton Self-Test – Pain Management   Adobe Sign PDF
Broughton Health Care Technician Test  Adobe Sign PDF
DHHS Criminal Records Check Transmittal Form  Adobe Sign PDF
Required Influenza Vaccination Policy and Attestation   Adobe Sign PDF
Broughton Self-Test – Competency   Adobe Sign PDF
RN Job Description   Adobe Sign PDF
LPN Job Description   Adobe Sign PDF
HCT CNA Job Description   Adobe Sign PDF
ADA Checklist  Adobe Sign PDF

Nurses will be tested on the following document:

Medication Administration Education Program  (PDF Only)                                                PDF

Caswell Developmental Center – Kinston, NC

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Required Documents   Adobe Sign PDF
Employee Information Sheet  Adobe Sign PDF

Central Regional Hospital – Butner, NC

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DHHS Criminal Record Check Consent Form and Release of Information   Adobe Sign PDF
Application for Exemption From Annual Influenza Vaccination  (PDF Only) PDF
Adverse Weather Policy   Adobe Sign PDF
Compact License Form   Adobe Sign PDF
Fast Track Test and Attestation   Adobe Sign PDF
Medical Clearance Form for Contract Nursing Service Provider Personnel (PDF Only) PDF
COVID-19 Vaccine Management System (CVMS) Registration   Adobe Sign PDF
Position Description Form – Professional Nurse (RN)   Adobe Sign PDF
Position Description Form – Licensed Practical Nurse (LPN)   Adobe Sign PDF
Position Description Form – Healthcare Technician I (HCT)   Adobe Sign PDF
Central Regional Respiratory Protection Medical Surveillance Questionnaire   Adobe Sign PDF
DSOHF Infection Prevention and Control Requirement Attestation Statement Adobe Sign PDF
Human Rights and Confidentiality Attestation Adobe Sign PDF

Documents to Review:

Compliance Checklist  (PDF Only)                                                                         PDF
Memo Regarding Levels of Observation  (PDF Only)                                                                  PDF

Nurses will be tested on the following documents:

Medication Administration Education Program Study Guide (PDF Only)                                       PDF
Fast Track Testing Materials for Nurses (PDF Only) PDF

CNAs will be tested on the following documents:

Fast Track Testing Materials for CNAs (PDF Only)                                                                          PDF

Cherry Hospital – Goldsboro, NC

 

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Cherry Hospital Professional Nurse Job Description   Adobe Sign PDF
Cherry Hospital Licensed Practical Nurse Job Description   Adobe Sign PDF
Cherry Hospital Health Care Technician I Job Description   Adobe Sign PDF
Cherry Criminal Record Check Consent Form and Release of Information   Adobe Sign PDF
Required Influenza Vaccination Policy and Attestation   Adobe Sign PDF
Guidelines for Availability of Hepatitis B Vaccine   Adobe Sign PDF

Nurses will be tested on the following two documents:

Basic Concepts in Psychiatric Nursing  (PDF Only)                                                                            PDF
Medication Administration Education Program Study Guide (PDF Only)                   PDF

Longleaf Neuro-Medical Treatment Center

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LPN Job Description   Adobe Sign PDF
HCT Job Description   Adobe Sign PDF

Murdoch Developmental Center

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DHHS Criminal Record Check Consent Form and Release of Information   Adobe Sign PDF

Walter B. Jones, ADATC – Greenville, NC

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Registered Nurse Banded Position Description   Adobe Sign PDF
Health Care Technician I Job Description   Adobe Sign PDF
Health Care Technician I Specifications   Adobe Sign PDF
DHHS Criminal Record Check Consent Form and Release of Information   Adobe Sign PDF