WELCOME TO VOLUNTEER SERVICE

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1 WELCOME TO VOLUNTEER SERVICE Prevention & Recovery Center Dear New Volunteer, It is a sincere pleasure to welcome you to the Volunteer Service of Memorial Hermann Prevention and Recovery Center (PaRC). The men and women who volunteer their time play an important role in the day to day operations of the PaRC. Volunteers have the opportunity to make an impact on both patient areas and non-clinical areas as part of our team dedicated to providing the "Best of the Best" in service and care. The Memorial Hermann Healthcare System (MHHS) is the largest not-for-profit hospital system in Texas and tenth largest in the US. Our system includes 11 acute care hospitals, many outpatient and specialty clinics, and PaRC, Memorial Hermann's alcohol and drug treatment center. The program began at a psychiatric hospital in 1982, but was relocated and renamed the Memorial Hermann Prevention and Recovery Center (PaRC) in late The PaRC, then a 42-bed treatment center for adults, thrived in the new Texas Medical Center location and within 6 years had outgrown the building. With a full census and lengthy waiting list, the PaRC was relocated again, this time to a larger facility and campus. The new PaRC campus, located 3 miles north of 1-10 on Gessner Road, features 110 beds and offers detoxification, residential treatment, day and evening outpatient programs, a family program, and aftercare for adults. Moving from a 25,000 square foot building into newly renovated buildings with 140,000 square feet of space allowed the PaRC to expand services. An adolescent residential treatment program for teens ages 13 to 17 was opened in The PaRC also expanded outpatient locations to include The Woodlands, Sugar Land, Clear Lake, Pearland Lake Jackson and Katy. With a 29 year history of service excellence to the Houston community and beyond, the PaRC continues to bring its experience, depth, and expertise to the forefront of alcohol and drug treatment. Incorporating the newest medical approaches along with proven treatment models and methodologies, PaRC's clinical teams and the entire staff are dedicated to delivering exceptional patient care experiences on a daily basis. Thanks to persons like you, the Volunteer Service continues to grow and give invaluable service to the community. Sincerely, Matt Feehery, CEO As of

2 Prevention & Recovery Center Date of Application: VOLUNTEER APPLICATION Personal Information It is our policy to keep this information confidential. Name: (First) (MI) (Last) Date of Birth: Social Security: Sex: MF Home Address: City: Zip: Home Phone: Cell Phone: Occupation: Business Address.. City:.Zip: Are you a person in recovery? Yes No Are you alumni of the PaRC Yes No If yes, how long have you been clean and sober? If not, how did you find out about us? Why do you want to volunteer with the recovery community? List Day(s) and Shift you can work regularly each week: Sun Mon Tues Wed Thurs Fri Sat 9 am 12:30 pm 1:00 pm 5:00 pm 5:30 pm - 9:00 pm As of

3 Please list two personal references: (long-time friend or for those in recovery, a 12 step sponsor) Name: Phone #: Address: City:,State: ----'Zip: Name:.Phone #: Address:.City: State:.Zip: In case of an emergency, notify:. Relationship: Home Phone # Work# Do you have a relative working at this Memorial Hermann Hospital? YES NO If yes, give Name: Position: IN SUBMITTING THIS APPLICATION FOR MEMBERSHIP IN THE VOLUNTEER SERVICE OF MEMORIAL HERMANN PREVENTION AND RECOVERY CENTER (PaRC), I AM AWARE THAT SERVING AS A VOLUNTEER IS A PRIVILEGE CARRYING WITH IT HIGH TRUST AND RELATED OBLIGATIONS. I AGREE TO FULFILL MY SERVICE COMMITMENT AND TO CONFORM TO ALL RULES AND REGULATIONS OF THE VOLUNTEER SERVICE PROGRAM. Signature Date [2 As of

4 Have you ever been convicted of, or been on probation for, or deferred adjudication for, or are you awaiting trial for, or on probation for, or deferred adjudication for any felony or misdemeanor? YES NO If yes, please explain and give dates: Disposition: Court: Nature of CrimeDate (Convictions will not necessarily disqualify an applicant- All facts and circumstances will be considered). I hereby certify that all the information contained on this application is true and complete. I authorize the Memorial Hermann Healthcare System to contact all sources necessary to verify this information and to check references as it may see fit. I understand that any misstatement or omission on this application is cause for loss of volunteer privileges. Signature Date MEDIA CONSENT: I,, hereby understand that my photograph may be taken for the purpose of promotion of services at Memorial Hermann Healthcare System which is deemed appropriate. I am aware I will not receive payment of any kind for my participation and grant Memorial Hermann Healthcare System the rights to use regardless of my future association with the facility and for an unrestricted time. Signature Date [3 As of

5 PRE-VOLUNTARY DISCLOSURE & RELEASE VOLUNTEER S FULL NAME Any Other Name You Have Volunteered Under: Social Security No.: Date of Birth: Current Address: City: State: Zip: Driver's License No.: State: Pursuant to the requirements of the Fair Credit Reporting Act, I acknowledge that a consumer report and/or investigative consumer report may be made in connection with my application for volunteering with prospective facilities. I understand that these investigative background inquiries may include credit, consumer, criminal, driving, prior volunteering and other reports. These reports may include information as to my character, work habits, performance and experience, along with reasons for termination of past volunteering from previous facilities. Further, I understand that agents may be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil and other experiences, as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency to furnish the above mentioned information. A photocopy of this authorization shall have the same effect as the original. I understand the information obtained will be used as one basis for volunteering or denial of volunteering. I hereby discharge, release and indemnify prospective school, their agents, servants and schools, and all parties that rely on this release and/or the information obtained with this release from any and all liability and claims arising by reason of the use of this release and dissemination of information that is false and untrue if obtained from a third party without verification. It is expressly understood that the information obtained through the use of this release will not be verified by investigating agents. The authorization granted herein expires one year from the date hereof. I have read and understood the above information, and asse1t that all information provided by me is true and accurate. If you are under the age of eighteen, the signature of a parent or guardian must be obtained. VOLUNTEER S SIGNATURE DATE: PARENT/GUARDIAN SDATE: If you are denied voluntary, either wholly or partly because of information contained in a consumer report, a disclosure will be made to you of the name and address of the investigative agency making such report. Upon your written request within a reasonable period of time, the investigative agency compiling the report will make a complete and accurate disclosure of the nature and scope of the investigation. 1 A consumer report may consist of enrollment records, educational verification, licensure verification, driving record, previous address and public records relative to criminal charges. 2 An "Investigative Consumer Report" means a consumer report or portion thereof in which information on a consumer's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with persons having knowledge.

6 Prevention & Recovery Center Volunteer Program Guidelines Memorial Hermann Prevention and Recovery Center (PaRC) welcomes anyone wishing to volunteer. We provide qualified volunteers with an exciting and education experience in a variety of program/service areas. Our hope is you find that you get back more than you give. Volunteer Positions are a combination of Clerical Assistance and Patient/Visitor interaction. Requirements/Restrictions Must be 18 years or older. If a PaRC alumni, must be one year sober and a graduate of Aftercare. If in recovery from another program, must be 18 months sober and actively working in a recovery program and provide a letter from your sponsor. Pass a background check and TB test and have flu shot. Participate in New Employee Orientation. Commit to one year and at least 3 hours per week. Adhere to dress code of business casual no jeans. Be on time to your shift. Notify staff if you leave your station Volunteers who are going to be late or unable to work their shift must contact the Volunteer Coordinator in advance of their absence. Smile, make eye contact and treat everyone with dignity and respect. Direct patients, family members and visitors as needed. If patients, family members or visitors have questions you cannot answer, please contact a staff member Do not read a patient's chart under any circumstances. Do not give medication to patients. Do not give food or drinks to patients unless approved by staff. Do not be discourteous to a patient, family members or visitors. If someone does something or says something that is offensive to you, do not respond in kind; report it to a staff member. Do not run errands, buy cigarettes, give money, offer transportation or housing to any patient, family member or visitor Do not give your address or phone number to patients, family members or visitors. Volunteers will not engage in a romantic, sexual or business relationship with a patient or family member. Violation results in immediate dismissal. Do not ask Doctors or Nurses for professional or medical advice. Volunteers will be asked to leave the Volunteer Program if he or she cannot adhere to all of these requirements. Volunteer Date

7 Memorial Hermann Healthcare System Volunteer Confidentiality Agreement IMPORTANT: Please read all sections. If you have any questions, please ask before signing. 1. Confidentiality of Patient Information As a hospital Volunteer, I understand and acknowledge that: (i) services provided to patients are private and confidential; (ii) to enable such services to be performed, patients provide personal information with the expectation that it will be kept confidential and used only by authorized persons as necessary; (iii) all personally identifiable information provided by patients or regarding medical services provided to patients, in whatever form such information may exist, including oral, written, printed, photographic and electronic formats (collectively, the "Confidential information") is strictly confidential and is protected by federal and state laws and regulations that prohibit its unauthorized use or disclosure; and (iv) in the course of my volunteer activities with Memorial Hermann Healthcare System, I may see or learn of Confidential Information. 2. Disclosure, Use and Access I agree that, except as authorized in connection with my volunteer assignment, I will not at any time use, access or disclose any confidential information to any person (including but not limited to other volunteers, friends and family members). I understand that this obligation remains in full force during the entire period of my volunteer activities and continues in effect after my volunteer activities. 3. Confidentiality Policies I agree that, even though I am a volunteer, I must and will comply with the same confidentiality policies that apply to all staff at the hospitals(s). 4. Return of Confidential Information At the end of my volunteer work, or at any other time upon request, I agree to promptly return to Memorial Hermann Healthcare System all copies of any Confidential Information then in my possession or control (including all printed and electronic copies). 5. Periodic Certification I understand that I am required to provide a written certification each year that I have complied in all respects with this Agreement. Such written certification will be on a form provided by Memorial Hermann. 6. Requirement I understand that my agreement to abide by the confidentiality policies, and this Agreement, is a condition of my volunteer activities with Memorial Hermann. I understand that failure to comply with confidentiality policies will result in my no longer being accepted for volunteer activities. Signature Date Printed Name

8 VOLUNTEER PROGRAM PROOF OF PPD (Purified Protein Derivative) Test (also known as TB Test) and FLU SHOT Date skin test given Site test given: Right arm Left arm Test administered by Date result read: Result: Negative Positive Result read by Comments, if any FLU SHOT VERIFICATION ADMININSTERED BY (Signature) (Please print full name) Date TB Tests and Flu Shots are administered free of charge at Memorial Hermann Memorial City by the Occupational Health nurse. Please call to schedule an appointment.

9 THE VOLUNTEER CODE OF ETHICS THE VOLUNTEER IS RESPONSIBLE Serving as a Volunteer is a privilege carrying high trust and related obligations. THE VOLUNTEER IS ETHICAL The Volunteer is expected to conform to the same high standards of behavior as the professional staff of the hospital. THE VOLUNTEER IS LOYAL When evaluated objectively, the conduct of the Volunteer is consistent with and promotes the best interests of the patients, the staff and the hospital. THE VOLUNTEER IS DISCREET The Volunteer holds in deep respect the doctor-patient-hospital relationship and protects the confidential nature of all privileged information to which there may be access. THE VOLUNTEER IS DISCIPLINED Aware of the functions inherent in the Volunteer Role, the Volunteer serves patients and visitors. In addition, the Volunteer is sensitive to the restrictions of his/her position and refers medical questions, religious matters, hospital policy and business affairs to the appropriate authority. THE VOLUNTEER IS OBJECTIVE The Volunteer exercises tolerance and respect for all persons different from self and for those who hold viewpoints different from those the Volunteer endorses. The Volunteer avoids controversial discussions with patients and staff. THE VOLUNTEER IS CONSTRUCTIVE Criticism or other information affecting the patient, staff, Volunteer Service or hospital is handled by relaying it only to the Department of Volunteer Services for proper referral. THE VOLUNTEER IS SELFLESS In giving service for the public good, the Volunteer does not seek medical advice or special privileges derived from his/her unique relationship to the hospital.

10 I'm a Volunteer. What is "HIPAA" and what does it mean to me? by Kasey Cooksey, Volunteer Services Coordinator, Memorial Hermann Hospital HIPAA is the Health Insurance Portability and Accountability Act of It deals with patient privacy issues. Are HIPAA issues for employees the same for volunteers? Yes, you are considered part of our workforce. Are volunteers held accountable for breaches of information in the same ways as employees? Yes, and bear in mind there is a potential for fines up to $250,000 and 10 years in Prison, depending on the offense. This penalty is directed specifically at employee or volunteer, not the hospital or the department. The individual committing the breach of information is held personally accountable. What is a breach of information? 1. Carelessness- u n i n t e nt ional breaches in confidentiality, when a worker reveals patient Information to himself/herself or others by accident. For example, discussing patient information in a public area or leaving a computer unattended that is showing patient information on the screen. 2. Curiosity or Concern (no personal gain) - intentional access to patient information that is not needed for patient care, for reasons o t h e r than personal gain. For example, viewing your own records, looking up a friend's address or birthday, reviewing a Patient record out of concern or curiosity. 3. Personal Gain or Malice- Accessing, reviewing, or discussing p a t i e n t information for personal gain. For example, reviewing a patient record for information (on to be used in a personal relationship or copying a patient mailing list for personal use, or to be sold. The information in a patient's medical record BELONGS TO THE PATIENT-- you may not give that information to anyone unless a) that patient has asked you to' do so b). it is necessary for continuum of care c) it is necessary for payment to the hospital from an insurance company (When a patient is admitted, they --or their family member-- sign a r e l e a s e of information for payment and continuum of care purposes)

11 The patient's medical record itself BELONGS TO US. If that patient wants a copy of that record, a copy of an x-ray, etc., they must go through the proper channels to acquire it s o m e clinics and units will provide copies of the information to a patient as a courtesy during their visit (no records release needed). If not, the patient must request the information through medical records. There is a fee for various medical records requests if the information is given directly to the patient. If the information is going to a doctor there is usually no charge, all that is needed is a release of information for that transaction. Fax machines that receive confidential information should not be in a public area, Can patient information be sent via ? No, patient information may not be sent via (outside the Memorial Hermann System) unless the patient has signed a release saying that he or she understands that the information is not guaranteed secure due to the implications of internet security. General Rules to Follow Regarding Patient Confidentiality:.. Access only the patient information you need to perform your job. Avoid discussing patients with others, especially in public places such as elevators, cafeterias, bus stops, halls, etc.... Be sure that schedules (cath lab, operating room, etc.) are kept in a secure area, and not in public view... Keep patient charts closed when not in use. If charts are left on an "express desk", the desk should be closed when not in use... White boards should be kept out of main public hallways, and should not contain information that links a patient to his or her diagnosis.