STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16*

Transcription

1 STUDENT VOLUNTEER APPLICATION *Minimum Age for volunteers is 16* CONTACT INFORMATION Name: Date: Address: Home Phone: Cell Phone: Over 16? Over 18? EMERGENCY CONTACT INFORMATION Emergency Contact: Relationship: Home Phone: Cell Phone: SCHOOL INFORMATION Select one: High School Student College Student Other: School Name: Major/High School Programs: Current Grade level: STUDENT AVAILABILITY Please indicate your availability: Start Date: End Date: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Preferred amount of hours per week: Please list any pre-planned holidays or vacation days scheduled: T-shirt Size (unisex sizes): Small Medium Large X-Large Would you be willing to drive to one of our remote locations? Yes No Bowie Kent Island Odenton Waugh Chapel *For office use only Date Received: Orientation: Placement: Immunizations: Badge Appointment Scheduled for: Notes:

2 Personal Questions (Please write legibly and be specific!): Is there a particular area of the hospital where you would like to gain experience? What interests you in volunteering in the hospital environment? What do you hope to gain from your experience? What are your plans for the future? Please list previous volunteer experience: List 3 characteristics that describe you: 1.) 2.) 3.) List 3 areas of opportunities for growth: 1.) 2.) 3.)

3 VOLUNTEER AND INTERN AGREEMENT In consideration of, (volunteer/intern) having the opportunity to participate in a volunteer/intern program at Anne Arundel Medical Center ( AAMC ), I agree to the following: 1. Release of Liability: I understand that the intern/volunteer will be working in a medical facility and may be exposed to a full range of human medical conditions from minor illness to death. I hereby release, discharge and agree to hold harmless AAMC, its affiliates, employees, officers, agents and directors from any and all liability, claims or demands of any nature including but not limited to, those for personal injury, death, and/or property damage or loss, of any nature whatsoever which may be incurred by the volunteer/intern in any way related to the volunteer/intern s participation in the Program. I agree to hold harmless and indemnify AAMC, its affiliates, employees, officers, agents, and directors, from any liability or damages incurred as a result of any acts or omissions of the volunteer/intern. 2. Immunizations: I understand and agree that I must provide AAMC with evidence of a Physician s signature indicated on the immunization requirements form before beginning with the Program. 3. Program Requirements: The intern/volunteer must comply with the following requirements: a. Notify the Volunteer Coordinator if unable to attend a scheduled shift b. Arrive on time for every scheduled shift or activity and must stay until its completion c. Wear the proper uniform and ID badge while participating in the Program d. Retain any documentation of working hours provided at the end of the Program, and understand that the Volunteer Office may not be able to provide this documentation at a future date. e. Comply with all rules, regulations and policies of AAMC. 4. Background Checks: I understand and agree that, as a condition of being selected as a volunteer at Anne Arundel Medical Center, AAMC will conduct a criminal background check. My signature below constitutes my authorization for AAMC or its agents to check my background. I waive and release AAMC and its agents from any and all claims I may otherwise have with respect to any such criminal background check. Background checks are not completed on minors. 5. Legal Guardians for Minor Intern/Volunteer: I attest that I am the parent or legal guardian of the intern/volunteer and that I am authorized to sign this Agreement on behalf of the intern/volunteer. I hereby grant permission for the intern/volunteer to participate fully in the Program. Furthermore, I hereby authorize AAMC to provide emergency medical care that may become necessary during the intern/volunteer s participation in the Program, and I assume the responsibility for costs of care. If volunteer/intern is under 18 year of age, the signature of a parent or guardian is required. I understand that this is an application for and not a commitment or promise of volunteer opportunity. It is the policy of the Volunteer Office of Anne Arundel Medical Center to provide equal opportunities without regard to race, religion, national origin, gender, sexual preference, age, or disability. Volunteer Printed Name: Volunteer Signature: Date: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

4 ANNE ARUNDEL HEALTH SYSTEM CONFIDENTIALITY AGREEMENT I,, understand that as a workforce member/contractor/vendor of Anne Arundel Health System ( AAHS ), or an individual who has been given specific authorization by AAHS to participate in certain confidential patient care or other activities, I have a responsibility to safeguard patient privacy, Protected Health Information ( PHI ), as well as other AAHS confidential business information by assuring that access, use, and disclosure of the information is made by myself or others ONLY when the Need to Know exists. I understand, acknowledge, and agree that my, as well as my coworkers and other individuals access to PHI is permitted ONLY when I or they need to know the information, and that all other access to PHI is STRICTLY PROHIBITED by state and federal law. Need to know is defined as OBTAINING, USING OR COMMUNICATING PHI or other AAHS employee or any other information which is REQUIRED for me to perform my specific job duties or as defined by the scope of my activities at AAHS. This pertains to PHI in the form of patient medical and personal information which is communicated orally or is accessed either by computer or in paper form, or which is used in preparing patient services such as dietary support, pharmacy support, or diagnostic support in the form of laboratory, radiology or other procedures. I may only obtain, use or communicate PHI on the specific patient to whom I am providing care or support services. PHI means individually identifiable health information which is a subset of health information, including demographic information collected from an individual and is created or received by a health care provider, health plan, or healthcare clearing house; and that which relates to the past present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual; or which there is a reasonable basis to believe the information can be used to identify the individual. I hereby agree not to OBTAIN, USE OR COMMUNICATE ANY PHI or other information about patients, employees or any other aspect of AAHS business which is not REQUIRED for me to perform my job or the scope of my activities at AAHS. I realize that to do so is a serious offense and that improper access, use, or communication of patient PHI or AAHS information results in harm to patients, employees and AAHS as a whole. I am aware that an offense of this nature will result in disciplinary action up to and including possible termination of my employment and/or contractual relationship with AAHS. I hereby agree to: 1. I will only obtain, use or communicate a patient s Protected Health Information (PHI), employee information, or other AAHS information on a Need To Know basis. 2. I will not openly discuss, nor be careless with, a patient s Protected Health Information (PHI), employee information, or other AAHS information in a manner that my conversation may be overheard, or file viewed, by someone who does not Need To Know the information. 3. I will not disclose my computer password or any other personal code or password which has been given to me by AAHS, and understand, acknowledge and agree that to do so is considered a breach of the confidentiality of the information which the password protects. 4. I will log off OR lock the computer EACH and every time I leave the computer for any reason. 5. I will not use my computer password to access confidential personal, employee, and/or family member information. 6. I will report any suspected or potential breaches of confidentiality to the Corporate Compliance Officer, and/or Privacy Officer. 7. As an employee, I will follow all Health System policies, including those that pertain to Confidentiality of Medical Records and Information (ERR3.1.05), Use and Disclosure of Protected Health Information (MR7.1.01), Faxing of Medical Information (MR7.1.04), the Corporate Compliance Plan (ADM1.1.64), and Computing and Electronic Communications Usage (HR8.3.20) 8. As an employee, I have received and will abide by the Confidentiality Policy(HR8.2.05) and Breach of PHI & Sanctions(ADM1.1.75) 9. As a contractor/vendor, I will abide by all federal and state laws regarding confidentiality of Protected Health Information. In order to create a password, please provide the last four digits of your Social Security Number ( ) and the month and day of birth ( / ). First Name MI Last Name Date Signature Department/ Organization/ Company

5 Anne Arundel Medical Center - Student Volunteer Immunizations Form Immunizations must be complete upon application submission in order to be selected to volunteer Student Name: Date of Birth: / / Two-Step Mantoux Tuberculosis Tests OR QuantiFERON-TB Gold (must be within the last 12 months) Chest X-Ray (only required if TB test is positive) REQUIRED IMMUNIZATIONS Test Dates Given & Results Notes TB Test #1 Given: / / Read: / / MM: TB Test #2 Given: / / Read: / / MM: Required for all students MMR Vaccine Series or Titer Varicella Vaccine Series or Titer Flu Vaccine (current year) Tdap (must be within the last 10 years) Hepatitis B Vaccine Series or Titer Chest X-Ray (MM/DD/YY): Date Taken: / / 2.) / / Titer: Date Drawn: / / 2.) / / Titer: Date Drawn: / / 2.) / / 3.) / / Titer: Date Drawn: / / Required for all students Required for all students Required yearly October-March for all students *Additionally required for clinical environments *Additionally required for clinical environments HEALTH CARE PROVIDER SIGNATURE (Dr., Nurse, NP, PA, DO) This form will not be accepted if not signed by a health care provider. Printed Name: Phone: Address: Signature: Date Completed: / /

6 HIGH SCHOOL STUDENT VOLUNTEER RECOMMENDATION FORM (AT LEAST ONE RECOMMENDATION REQUIRED FOR HIGH SCHOOL STUDENTS), who is applying to Anne Arundel Medical Center Volunteer Program, has the following attributes that demonstrates his/her ability to be a good team member: Describe the reliability and willingness of the applicant. In your opinion, will he/she be able to commit to volunteering at a hospital? Has the applicant maintained regular school attendance? Yes No Volunteers who work in our hospital tend to have frequent contact with very sick people and their families. In light of his/her personality and current level of maturity, do you feel comfortable recommending the applicant for placement in a hospital setting? Why or Why not? Teacher, Guidance Counselor, or Principal Signature: Printed Name: Date: Title: Phone Number: School Name:

7 If over 18, Please complete the following form:

8 (KEEP THIS PAGE FOR FUTURE REFERENCE) Requirements for Student Volunteers: Must be 16 years of age or older by orientation date High School Students: Must return attached High School Student Volunteer Recommendation Form (to be completed by a teacher, guidance counselor, principle, etc). College Students: must be in the process of obtaining a two or four year degree. Able to commit to at least three hours per week of volunteering in an assigned placement Available to attend required orientation, if placed in a position Provide documentation of required immunizations, including, but not limited to, MMR, Varicella, Hepatitis B, Tdap, Flu (current year), and Tuberculosis screen Friendly, compassionate, attentive and a willingness to learn Dedication: We require a minimum of one 3-hour block of time per week to volunteer at your assigned area. Assignments are based upon strength of application and availability. No assigned areas are guaranteed. Immunizations: Immunizations are a requirement of the healthcare environment. Please turn in your form with your application as only students who have complete immunization records will be selected. If you are in process of a shot series, please turn in what you have and we will collect additional documentation if selected. Volunteer Process: 1. Complete student volunteer application and immunization requirements and return by the deadline. Please be sure to include your availability in your application. 2. If selected, you will be contacted by the Volunteer Coordinator who will provide you with your assigned department and shift day(s) and time(s). 3. Students who have accepted their placement offer will be required to attend a student volunteer orientation. Students will learn about AAMC culture, policies, procedures, and the expectations of the volunteer program. 4. Attend scheduled department training and begin volunteering. Application Due Dates: Fall: August 1 Spring: January 1 Summer: May 1 Follow-up: You will be contacted by the Volunteer Services office if you have been selected for placement at Anne Arundel Medical Center. Questions or concerns? Please volunteer@aahs.org. Completed packets can be mailed or faxed to: Anne Arundel Medical Center Volunteer Services Attn: Student Volunteer Coordinator 2001 Medical Parkway Auxiliary Suite North Hospital Pavilion Annapolis, MD Fax: