??ࡱ? > ?? ? ? ???? ? ? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? o ?? ( bjbj??? 4 ??zf??zf? ?? ?? ?? ? U U ? ? ? ???? ? ? ? 8 ? ? ? t ! ! ! ! ! Q Q Q ? $ ? ? ?! f % ? 5 / / " 5 5 % U U ! ! : ? ? ? 5 j U ! U 8 ! ? ? 5 ? ? ? ? ? ! ???? p?? ?y? ???? ? j ? ? P 0 ? ? " " ? " ? ? D Q " s ? ? ? ? Q Q Q % % ? Q Q Q ? 5 5 5 5 ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? " Q Q Q Q Q Q Q Q Q : PARTICIPANT ACKNOWLEDGEMENT OF CHILD ABUSE AND NEGLECT REPORTING OBLIGATIONS Penal Code Sections 11165.7 and 11166 require specified health care practitioners and other persons who have knowledge of or observe a child in his or her professional capacity or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of child abuse or neglect to report the known or suspected instance of child abuse immediately or as soon as practicably possible by telephone and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. You are a person who is required to report known or suspected child abuse or neglect. The reporting obligations that you must fulfill are describe in Penal Code Sections 11165.7 and 11166, attached to this form. You must read this attachment. Your supervisor and administration should be notified whenever you believe that you may be required to report suspected child abuse or neglect. In addition, usually several hospital employees and medical staff members will learn about the same instance of suspected abuse or neglect. The patient?s attending physician (or other designated person) shall be responsible for making the reports or for identifying the member of the health care team who shall assume this responsibility. I have read the attached information regarding child abuse and neglect reporting obligations under California law. I understand that I must comply with these legal requirements, and I agree to do so. Date: __________________________ Signature: ___________________________________ Name: __________________________________________ (Healthcare Pathway Program Participant) (Printed ? Thank you) Signature: ___________________________________ (Witness) NOTE: The employer is required by law to attach a copy Penal Code Sections 11165.7 and 11166 to this form. Reference: Penal Code Sections 11165.7 and 11166 [ADVENTISTHEALTH:INTERNAL] N O P v s t u ? h i L M 8 9 B h ? ? ? ? ? ? ? ? ? ? ? ? ?????????????????????????????????????rf hz r h?M? 6?CJ aJ hx h?M? 6?CJ ]?aJ hx h;9? 6?CJ ]?aJ hx hx 6?CJ ]?aJ hx CJ aJ h?M? CJ aJ hz r h?M? CJ aJ h?M? 6? h?M? 5?h?M? h9G h9G 5?CJ aJ hFl? h?h! 5?CJ aJ hFl? h9G 5?CJ aJ hFl? h;9? 5?CJ aJ hFl? 5?CJ aJ ' O P t u h i L M 8 9 ? ? ? ' N O P ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? gd;9? gd?M? ??^??gd?M? gd9G $a$gd9G ? ? ? ? & ' + - / C D M N O P U ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ????????????껻??????????????????????|x?? h?|? h;9? j hFl? Uhx h?t j h?t U h?M? h?M? hz r h?M? h?M? h?M? 5?hj~T h?M? 6?CJ aJ h?M? 6?CJ aJ h;9? CJ aJ hj~T h?M? CJ aJ h?M? CJ aJ hz r h?M? CJ aJ hz r h?M? 6?CJ aJ h?M? 6?CJ aJ )? ? ? ? ? ? ? ? ? ? ? % & ' ( ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? gd9G gdx gd;9? $ % & ' ( ????????????? h?M? h?M? %hx hx B*CJ OJ QJ ^J ph h?t hx j hx UmH nH u 2 1?h:p?M? ??/ ??=!??"??#??$??%? ???? ?? B( D d @S?? ? ?h ? ? C ?D A ?, ? A H _ G l o b a l _ R G B _ H i g h R e s ? ?b ??' ?#?)e??eB?t1?c?? b' D ?D n ?Z' ?#?)e??eB?t1?c???PNG IHDR X C F?? pHYs .# .#x??v iTXtXML:com.adobe.xmp
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