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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 15 / 15

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ACKNOWLEDGEMENT

I certify that:

  • 1.

    I have read and understand the Corporate Compliance Plan and the Code of Conduct.

  • 2.

    I pledge to act in accordance with the Corporate Compliance Plan and the Code of Conduct.

  • 3.

    I will promptly report any conduct that I believe to be illegal or in violation of the Corporate

Compliance Plan or the Code of Conduct in accordance with the compliance concern reporting steps.

  • 4.

    I will seek advice from my supervisor or the Compliance Officer concerning appropriate actions that I may need to take in order to comply with the Corporate Compliance Plan or the Code of Conduct.

  • 5.

    I understand that failure to comply with this Code of Conduct may result in disciplinary action, up to and including termination of employment or affiliation.

_____________________________________ Signature

______________________________ Date

_____________________________________ Print Name

______________________________ Department

Relationship to the Hospital:

__

Employee

__

Non-Employed Medical Staff Member

__

Non-Employed Allied Health Professional

Member Board of Directors

__

Volunteer

__

Other

__

______________________________

NOTE (For Employees): The Corporate Compliance Plan Acknowledgement can be signed/acknowledged online via My HR. Please visit My HR at https://lawpb.c0tf.netaspx.com/lawson/portal (or click the My HR icon located on your computer’s desktop) to log in*. Once logged in, select the Forms link, then select the Compliance Plan-CH link.

CORPORATE COMPLIANCE PLAN 5/6/10

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