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North Carolina Division of State Operated Healthcare Facilities (DSOHF)
*The forms in this section are required for all NC DHHS DSOHF Facilities*
| Click link on right for Adobe Sign or PDF | ||
| * Agency Staff Expectations | Adobe Sign | * Interview Questions for Contract Registered Nurse or Licensed Practical Nurse | Adobe Sign |
| * Interview Questions for Contract Health Care Technician | Adobe Sign | |
| * DHHS Criminal Record Check Consent Form and Release of Information | Adobe Sign | |
| * Medical Clearance Form for Contract Nursing Service Provider Personnel (PDF Only) |
North Carolina Department of Revenue
| Click link on right for Adobe Sign or PDF | ||
| NC-4 EZ Employee’s Withholding Allowance Certificate (Short Form) | Adobe Sign | |
| NC-4 Employee’s Withholding Allowance Certificate (Long Form) | Adobe Sign |
North Carolina Department of Public Safety (Corrections)
| Click link on right for Adobe Sign or PDF | ||
| Candidate Nursing Requirements (PDF Only) | ||
| DPS Criminal History Record Check | Adobe Sign |
Broughton Hospital – Morganton, NC
| Click link on right for Adobe Sign or FormSite or PDF | ||
| Broughton Self-Test – Pain Management | Adobe Sign | |
| Broughton Health Care Technician Test | Formsite | |
| DHHS Criminal Records Check Transmittal Form | Adobe Sign | |
| Required Influenza Vaccination Policy and Attestation | Adobe Sign | |
| Broughton Self-Test – Competency | Adobe Sign | |
| RN Job Description | Adobe Sign | |
| LPN Job Description | Adobe Sign | |
| HCT CNA Job Description | Adobe Sign | |
| HCT CNA Job Description | Adobe Sign |
Nurses will be tested on the following document:
| Medication Administration Education Program (PDF Only) |
Caswell Developmental Center – Kinston, NC
| Click link on right for Adobe Sign or PDF | ||
| Required Documents | Adobe Sign | |
| Employee Information Sheet | Adobe Sign |
Central Regional Hospital – Butner, NC
| Click link on right for Adobe Sign or PDF | ||
| DHHS Criminal Record Check Consent Form and Release of Information | Adobe Sign | |
| Application for Exemption From Annual Influenza Vaccination (PDF Only) | ||
| Adverse Weather Policy | Adobe Sign | |
| Compact License Form | Adobe Sign | |
| Fast Track Test and Attestation | Adobe Sign | |
| Medical Clearance Form for Contract Nursing Service Provider Personnel (PDF Only) | ||
| COVID-19 Vaccine Management System (CVMS) Registration | Adobe Sign | |
| Position Description Form – Professional Nurse (RN) | Adobe Sign | |
| Position Description Form – Licensed Practical Nurse (LPN) | Adobe Sign | |
| Position Description Form – Healthcare Technician I (HCT) | Adobe Sign | |
| Central Regional Respiratory Protection Medical Surveillance Questionnaire | Adobe Sign | |
| DSOHF Infection Prevention and Control Requirement Attestation Statement | Adobe Sign | |
| Human Rights and Confidentiality Attestation | Adobe Sign |
Documents to Review:
| Compliance Checklist (PDF Only) | ||
| Memo Regarding Levels of Observation (PDF Only) |
Nurses will be tested on the following documents:
| Medication Administration Education Program Study Guide (PDF Only) | ||
| Fast Track Testing Materials for Nurses (PDF Only) |
CNAs will be tested on the following documents:
| Fast Track Testing Materials for CNAs (PDF Only) |
Cherry Hospital – Goldsboro, NC
| Click link on right for Adobe Sign or PDF | ||
| Cherry Hospital Professional Nurse Job Description | Adobe Sign | |
| Cherry Hospital Licensed Practical Nurse Job Description | Adobe Sign | |
| Cherry Hospital Health Care Technician I Job Description | Adobe Sign | |
| Cherry Criminal Record Check Consent Form and Release of Information | Adobe Sign | |
| Required Influenza Vaccination Policy and Attestation | Adobe Sign | |
| Guidelines for Availability of Hepatitis B Vaccine | Adobe Sign |
Nurses will be tested on the following two documents:
| Basic Concepts in Psychiatric Nursing (PDF Only) | ||
| Medication Administration Education Program Study Guide (PDF Only) |
Longleaf Neuro-Medical Treatment Center
| Click link on right for Adobe Sign or PDF | ||
| LPN Job Description | Adobe Sign | |
| HCT Job Description | Adobe Sign |
Murdoch Developmental Center
| Click link on right for Adobe Sign or PDF | ||
| DHHS Criminal Record Check Consent Form and Release of Information | Adobe Sign |
Walter B. Jones, ADATC – Greenville, NC
| Click link on right for Adobe Sign or PDF | ||
| Registered Nurse Banded Position Description | Adobe Sign | |
| Health Care Technician I Job Description | Adobe Sign | |
| Health Care Technician I Specifications | Adobe Sign | |
| DHHS Criminal Record Check Consent Form and Release of Information | Adobe Sign |