CTMP POR Compliance Attestation Form - In Program August 2016

POR Compliance Attestation The National Human Resources .035 Contingent Worker Policy requires all contingent/supplemental workers to attest receipt, understand, and abide by the KP Principles of Responsibility on or before their first day of work. Please complete the attestation form below. If you have any questions, please discuss them with your manager.First Name:Last Name:• I understand that the requirements in the Principles of Responsibility applies to me.• I have read, understood, and familiarized myself with the Principles of Responsibility.• If I have any questions about the Principles of Responsibility or any other Kaiser Permanente compliance policies and/or procedures that may apply to me, I will seek clarification from my contact at Kaiser.• I understand that I am expected to conduct myself in an ethical and responsible manner at all times, in accordance the Principles of Responsibility and any other Kaiser Permanente compliance policies and/or procedures that apply to me.• I agree to abide by the content of the Principles of Responsibility or any other Kaiser Permanente policy and/or procedures that may apply to me and acknowledge that the failure to comply with them can result in my no longer being able to work on assignments for Kaiser Permanente.• I understand that I am also required to report any suspected compliance or ethics concerns I become aware of. I further understand that I am protected from retaliation for reporting any such concerns.By my signature below, I acknowledge, understand, accept, and agree to comply with theserequirements. I also understand that failure to comply with these requirements may result indisciplinary action up to and including termination of assignments at Kaiser Permanente and ineligibilityfor future assignments.Signature_______________________ Date ___________________________Thank you for completing the Kaiser Permanente's Principles of Responsibility Attestation.1 August 19, 2016