Blue Folder Brigade

Correcting Deficiencies in Non-Compliant Blue Folders

Welcome to the Blue Folder Brigade (BFB) home page where you'll find the information you need to be an effective BFB member!!

  1. Getting Started
  2. Required Content In a Blue Folder
  3. Forms & Templates
  4. Audits
  5. Policies
  6. Bulletins, Presentations & Calendars
  7. Responsibilities of BFB Members
  8. Responsibilities of Chapter Lead
  9. Ordering Information
  10. FAQ'S
  11. Contact Information

Getting Started

What is "The Joint Commission" (TJC)?
What are Blue Folders?
What is the "BFB" (Blue Folder Brigade)?
BFB Contact List *UMHS Only*= Internal UMHS site

Required Content In a Blue Folder

Front Label
Employee File Contents Document
Job Description
Licensure/Certification/Registration (PSV/non-PSV)
Orientation Documentation
Performance Evaluation & Improvement Plans
Mandatories Overview
Competency Assessments
Ongoing Education Documentation

Forms & Templates

Audit Register
Blue Folder Report Instructions
Employee File Contents
Evaluation Forms (Staff Form, Leadership Form, Nursing Forms)
File Retention Standards
Front Label Template
Licensure Monitoring Matrix
Manage Competencvy Data Entry Instructions
Manage Competency Report Instructions
MLearning Departmental Competency Assessment Template
MLearning Non-PSV Licensure/Certification/Registration Template
MLearning Mandatories Template
MLearning Ongoing Education Template
Notification of Licensure Action Template
Orientation Checklist
Helpful Links for New Employees
Orientation Documentation Waiver Template
Performance Expectations & Competencies
PSV Matrix
IE Print Settings for PSV
PSV Telephone Verification Form


Departments are required to audit the Blue Folder of every employee at least once annually. Audit results are entered into the Audit Tool in MPathways and are due by December 31st each year.

Accessing and using the Audit Tool
Blue Folder Report Instructions
Instructions for Auditing Blue Folders

Blue Folder labs are offered by Human Resources at various times throughout the year and will be announced via the newsletter.


Performance Management

Bulletins, Presentations & Calendars


2008 2009 2010 2011 2012 2013 2014 2015 2016
January April February January April January November March January
March July May June September May August
July October October September

Responsibilities of BFB Members

Attend meetings
Participate in audits
Share information and best practices
Help design and implement changes or incorporate additions to the implementation of The Joint Commission HR standards
Keep your department's blue folders current, accurate and compliant

Responsibilities of Chapter Lead

Keep BFB members updated with any changes in standards or practices
Facilitate regular BFB meetings
Provide education and resources on TJC requirements
Demonstrate institutional compliance by using data from blue folder audits

Ordering Information

Where/How to order Blue Folders and replacement tabs


Why do we have blue folders?
What do I do if the orientation documentation is missing?
What should I do with documents older than 3 years?
What should I do with the folder of an employee who terminated?
What if a person has two regular jobs at UMHS?
Do old (over 3 years) documents have to be removed?
What happens when an employee transfers departments?
Do temporary staff members need to have a performance evaluation?
Where do I get blue folders?
Who is required to have a blue folder?
What about faculty documents?
How long should I keep the blue folders?
What if the documentation is in MLearning?
Where should I direct any questions?

Contact us

E-Mail us at for the following:

You need to add or remove someone from the BFB list
You have been newly assigned to be a BFB member
You have a best practice to share
You have any questions or suggestions