North Hawaii Community Hospital Volunteer Services Application Today s Date: Name: Address: City/State/Zip: Home Phone: Business Phone: Social Security #: Birth Date: Are you 18 years of age or older? Yes No Person to call in case of emergency: Telephone #: Personal Physician: Telephone #: Explain why you want to be a hospital volunteer: Volunteer Experience: Organization Position Date(s) Weekly Hrs. Worked Paid Experience: Organization Position Date(s) Weekly Hrs. Worked Training / Special Skills / Interests: List community organizations, clubs, and etc. to which you belong and any offices held: Languages Spoken: Read: 1
Please check the days / shifts you will be available to work on a regular basis: MON TUE WED THU FRI SAT SUN 8am-12pm 12pm - 4pm 4pm - 8pm If accepted, will you have reliable transportation? Yes No How did you become interested in the NHCH Volunteer Services Program? I agree to uphold the vision, purpose and policies of North Hawaii Community Hospital and the NHCH Volunteer Services program. I also agree to attend basic orientation and regular in-service education as needed. I understand that all NHCH volunteers must have a yearly tuberculin (TB) health clearance. I understand that punctual and dependable attendance is a requirement of my service. For valid absence, I will notify my supervisor, the Director of Holistic Care Services and will assist in finding a trained replacement if necessary. If accepted, I acknowledge that continued membership is subject to the rules and regulations of the program, as they may change from time to time. North Hawaii Community Hospital is an equal opportunity provider and does not discriminate in its selection of volunteers, regardless of their race, ethnicity, national origin, citizenship, physical or mental handicap, pre-existing medical condition, age, sex, education, spiritual beliefs, fraternal or other affiliation. A satisfactory background verification and criminal record check are required for volunteer positions. I authorize North Hawaii Community Hospital to conduct these background and record checks. Signature: Date: 2
CODE OF ETHICS AGREEMENT If accepted as a volunteer for North Hawaii Community Hospital, I agree that: 1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors, or employees and will not seek to obtain confidential information about or from a patient. 2. My services are donated to North Hawaii Community Hospital without compensation or future employment and are given for humanitarian or charitable reasons. 3. I shall conduct myself with dignity, courtesy and consideration of others and shall endeavor to make my work professional in quality. 4. I shall make a firm commitment of my time, talents, and skills for a definite period of time. I intend to be faithful to my commitment. If I am unable to report for duty, I will notify my supervisor and the Director of Holistic Care Services. 5. I shall attempt to resolve any problems related to my volunteer work, and, if unsuccessful, I will work with the Director of Holistic Care Services in order to resolve these problems. 6. I shall at all times uphold the vision, philosophy and quality standards of North Hawaii Community Hospital. 7. I shall make my best effort to fulfill my commitment to the hospital by completing all assignments that I accept. 8. I understand that the Director of Holistic Care Services reserves the right to terminate my volunteer status as a result of any of the following: a. Failure to comply with hospital rules and regulations b. Unsatisfactory attitude, work or appearance c. Absences without notification d. Any other circumstances which, in the judgment of administration, would make my continued service as a volunteer contrary to the best interest of North Hawaii Community Hospital I have read and understand the VOLUNTEER CODE OF ETHICS AGREEMENT. Volunteer s Name Date Parent s Signature (if volunteer is under 18 yrs. old) Date Note: Jr. Volunteers must be at least 16 yrs. old. 3
CONFIDENTIALITY INFORMATION North Hawaii Community Hospital is committed to ensuring confidentiality of records and related information for all patients, associates and hospital business. Full consideration is given to patients rights for privacy concerning all aspects of their medical program. All communications regarding their care will be treated as confidential information. Access to any of this information is limited only to those health care professionals who have need of the information to fulfill their duties. All associates, volunteers and physicians who have access to information about patients, associates or hospital operations which is of confidential nature will be prohibited from discussing or revealing such information in any unauthorized manner. Confidential information includes, but is not limited to, medical records, associate records, information gained from service on hospital or medical staff committees, information gained from patients, from families and friends of patients, associates, volunteers, external agencies, media or medical staff. Any breach of confidentiality represents a failure to meet the professional and ethical standards expected and constitutes a violation of this policy. A breach need not take the form of a deliberate attempt to breach confidentiality but includes any unnecessary or unauthorized informal discussion of confidential information. Remember, it s not only what you say but also what you write and where it is sent. Remember to discuss patient or sensitive information of any nature only in a private area and then only with those who are directly related to the care of that patient or have a right to deal with that sensitive information. Patient and other sensitive information should be safeguarded to preserve the records against loss, destruction, tampering and from access or use by unauthorized individuals. Any computer system used within the course of your volunteering is to be used solely to perform your job responsibilities at NHCH. You are responsible for the computer usage conducted under your assigned profile and you will not share your password or computer usage with any other person. My signature below verifies that I have read a copy of the above and agree to comply with all of the above. Volunteer Name (please print) Signature Date: 4
KROLL DISCLOSURE AND AUTHORIZATION TO OBTAIN INFORMATION In connection with my application to become a volunteer with North Hawaii Community Hospital ( Company ), I authorize Company to request a consumer and/or investigative consumer report on me from KROLL BACKGROUND AMERICA, INC. ( Kroll ). Such reports may include, but are not limited to, information as to my character, general reputation, personal characteristics and mode of living; discerned through employment and education verifications; personal references and interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number trace; present and former addresses; criminal and civil history / records; and any other public record. I authorize any person, business entity or governmental agency that may have information relevant to the above to disclose the same to Company and Kroll, including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus. I authorize Company to share such information only with parties in interest who have a need to know such information to protect them and their employees. Kroll does not sell or otherwise provide any of the information found in its background investigations to any party other than the Company. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to Kroll, if such is made within a reasonable time after the date hereof. I also understand that I may receive a written summary of my right under 15 U.S.C. 1681 et. seq. I agree that this authorization shall remain valid for the duration of my volunteer services with Company. I certify that the information contained on this Authorization form is true and correct and that my application or services may be terminated based on any false, omitted or fraudulent information. Signature: Date: IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY Last Name: First Name: Middle: Other Names Used: Years Used: Current Address: Street/PO Box City State Zip Code County Dates Former Address: Street/ PO Box City State Zip Code County Dates Social Security Number: Daytime Phone Number: Email Address: Driver s License #: State Issued: Date of Birth: Gender: Parent s Signature (if under 18) Note: Providing year of birth and gender information is strictly voluntary. This information will enable us to properly identify you in the event that we find adverse information during the course of a background check. 5
HEALTH CLEARANCE Prior to volunteer service, all volunteers at North Hawaii Community Hospital are required to obtain medical clearance from a physician. To my knowledge (name) is free from contagious disease is physically able to perform volunteer service has no health issues that would compromise his/her safety, the safety of others, or his / her performance of volunteer duties at North Hawaii Community Hospital. there is no contraindication against the above-named person performing volunteer activity at North Hawaii Community Hospital. COMMENTS: Physician s Name (please print) Signature Date 6
CONFIDENTIAL REFERENCE INQUIRY Two letters of reference per applicant are required, must be completed by the person referring the applicant and CANNOT be a relative. Name of Applicant: The person above has applied for a position as as has given your name as a reference. Name of Reference: Phone Number: Title/ Position: Company: Date: COMMENTS (Were there any problems? Would you re-hire? etc.) Name of person doing the reference (please print) Signature Please complete and return to: Arielle Faith Michael, Director Holistic Care Services / Volunteer Program North Hawaii Community Hospital 67-1125 Mamalahoa Highway, Kamuela, HI 96743 (808) 881-4416 Arielle.Michael@NHCH.com 7
CONFIDENTIAL REFERENCE INQUIRY Two letters of reference per applicant are required, must be completed by the person referring the applicant and CANNOT be a relative. Name of Applicant: The person above has applied for a position as as has given your name as a reference. Name of Reference: Phone Number: Title/ Position: Company: Date: COMMENTS (Were there any problems? Would you re-hire? etc.) Name of person doing the reference (please print) Signature Please complete and return to: Arielle Faith Michael, Director Holistic Services / Volunteer Program North Hawaii Community Hospital 67-1125 Mamalahoa Highway, Kamuela, HI 96743 (808) 881-4416 Arielle.Michael@NHCH.com 8