HOJA DE INTERVENCIÓN CON EMPLEADO

La política del Hospital Auxilio Mutuo es que todos los empleados cumplan con
las normas establecidas en el Hospital para garantizar el bienestar del
paciente, visitante y/o empleado.

Nombre: Israel Calo Fecha Evento: 01/30/2022

Puesto: Enfermero Graduado Lugar Evento: Intensivo
Quirúrgico
Departamento: Intensivo Quirúrgico Hora Evento: 7-3
# Empleado: ___________________________________ Turno Empleado: ___________________

Testigo(s) del Evento: ________________________________________________________________________

Nombre y puesto del entrevistador: Marisol González Vélez, Supervisora Clínica

Descripción del evento o situación:

El día 30 de enero de 2022 el enfermero Israel Calo, RN me informa que no podrá asistir al turno

7-3 del día 1 de enero de 2022 y llenado la licencia de ausencia de un día previamente con cargo

sin sueldo. Usted incumplió con el Manual del Empleado en el Inciso X Regla de Conducta

punto cinco en Ausencias anticipadas: Todo empleado que sepa de antemano que se va a ver

forzado a ausentarse de su trabajo en determinada fecha y hora, deberá hacer la notificación por

lo menos cinco días de anticipación a la fecha de la ausencia. Afectando los servicios del

Personal de Enfermería al cuidado directo al paciente.

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Certifico que he leído y Certifico que he discutido con el

recibido copia del Informe empleado el Informe

Firma del Empleado(a) Firma del Gerente o

Supervisor Inmediato

Fecha Nombre del testigo (Si aplica)

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Firma del Testigo

Rev. 01/2018
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Comentarios del empleado con relación a la situación del evento:

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Firma del Empleado(a)

Fecha

Rev. 01/2018
 HOJA DE INTERVENCIÓN CON EMPLEADO

La política del Hospital Auxilio Mutuo es que todos los empleados cumplan con
las normas establecidas en el Hospital para garantizar el bienestar del
paciente, visitante y/o empleado.

Nombre: ___________________________________ Fecha Evento: ___________________

Puesto: ___________________________________ Lugar Evento: ___________________
Departamento: ___________________________________ Hora Evento: ___________________
# Empleado: ___________________________________ Turno Empleado: ___________________

Testigo(s) del Evento: ________________________________________________________________________

Nombre y puesto del entrevistador: __________________________________________________________

Descripción del evento o situación:

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Certifico que he leído y Certifico que he discutido con el

recibido copia del Informe empleado el Informe

Firma del Empleado(a) Firma del Gerente o

Supervisor Inmediato

Fecha Nombre del testigo (Si aplica)

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Firma del Testigo

Rev. 01/2018
Nombre: Página # de ____

Comentarios del empleado con relación a la situación del evento:

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Firma del Empleado(a)

Fecha

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 HOJA DE ENTREVISTA

Nombre Empleado: ___________________________ Fecha Evento: ___________________

# Empleado: ___________________________ Lugar Evento: ___________________
Departamento: ___________________________ Hora Evento: ___________________
Puesto: ___________________________ Turno Empleado: ___________________

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Firma del Supervisor(a) Firma del Empleado(a)

Fecha
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 HOJA DE ENTREVISTA

Nombre Empleado: ___________________________ Fecha Evento: ___________________

# Empleado: ___________________________ Lugar Evento: ___________________
Departamento: ___________________________ Hora Evento: ___________________
Puesto: ___________________________ Turno Empleado: ___________________

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 HOJA DE ENTREVISTA

Continuación:

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Firma del Supervisor(a) Firma del Empleado

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Fecha
 INFORME

Nombre: +_____________________________________ Puesto: ________________________

Departamento: _____________________________ Fecha del evento: _______________

Personas relacionadas: ______________________________________________________

Descripción de la situación o Incidente: ______________________________________

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HALLAZGOS

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Firma Fecha
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INFORME

Nombre: ______________________________________ Puesto: ________________________

Departamento: _____________________________ Fecha del evento: _______________

Personas relacionadas: ______________________________________________________

Descripción de la situación o Incidente: ______________________________________

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HALLAZGOS

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Firma Fecha
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