Application for Volunteer Service Date: Name: First Middle Last Address: City: Zip: Phone: Home Work Cell E-Mail: Date of Birth: Are volunteer hours required? If yes, for what program? Number of hours needed & date due: Office use only: Date Submitted: Start date: Placement: Other Information: Date of Mantoux:
Student: Yes or No (Circle) School: Grade: Employed: Yes or No (Circle) Employer: Schedule Preference: A minimum 2 hour time commitment is required per shift. Times: (Circle) Morning Afternoon Evening Days: (Circle) M. T. W. Th. F. S. SU. Special skills or interests: Emergency Contact Information: Name: Relationship: Phone: Signature of Applicant: Date:
Possible areas of interest (circle all areas of interest) One-to-one visits Board games Trivia Entertainer Reading group Exercise class or walking group Active games (bowling, golfing) Escort resident to activities Birthday parties Assist with ice cream social Lead Shabbat Services Gift Shop Greeter Escort clients to ot/pt Card games Bingo Arts and Crafts Serve at special dinners Personal Shopper Outdoor walks Gardening Outings (van trips) Happy hour social Holiday / festival parties Religious programs Current events Activities Memory Care Activities Assisted Living Manicures Other: For more information contact: Carol Kvasnik, Director of Volunteer Services at 952-939-l627 or ckvasnik@sholom.com
SHOLOM RELEASE FORM I hereby consent to the use of my photograph(s) (and/or any copies of my photograph(s)) and my name in promotional materials produced and/published/submitted by Sholom, such as: 1. Official publications, documents, programs, marketing brochures and presentations of Sholom Community Alliance 2. Printed communicative media (e.g., American Jewish World or other newspapers) for promotional use of Sholom Community Alliance 3. Electronic communicative media (e.g., worldwide website) for promotional use of Sholom Community Alliance I understand that signing this release form does not guarantee publication. Printed Name Signature Address Telephone Number Signature of Responsible Party (If appropriate) Date
VOLUNTEER CONFIDENTIALITY STATEMENT AND HIPAA ACKNOWLEDGEMENT As a volunteer of Sholom Community Alliance, there is a need for you to be aware of the requirements in regards to any confidential and protected health information associated with Sholom Community Alliance. A volunteer includes a permanent, occasional or seasonal volunteer. Confidential information is considered to be any information that is generally known about Sholom Community Alliance s residents, tenants, clients, employees, business operations or services. Confidential information includes, but is not limited to, all residents, tenants, clients information, employee information, financial information and any information related to computer access or data whether oral, electronic or paper. Therefore, any information that a volunteer obtains from their volunteer activities is to be kept confidential. Each volunteer at Sholom Community Alliance is responsible to: Use Protected Health Information and/or Sholom Community Alliance confidential information only while volunteering with Sholom Community Alliance. o Resident/tenant/client medical records are confidential and are to be accessed on a need to know basis only. o You are expected not to read medical records or discuss medical situations. In the event you are asked to handle confidential and protected health information use your best effort to secure all confidential and protected health information. Do not release or share any confidential and protected information with anyone. If you receive a request to share or release information report immediately to the Director of Volunteer Services. Prevent disclosure of any computer access and/or disclosure of computer confidential information. Do not email resident/tenant/client information unless you have encrypted that information. There are regulations requiring that any disclosure of protected health information (inadvertent or otherwise) be reported to the resident/tenant/client. As a volunteer you are required to report, within three days or earlier, any disclosure of information to the Director of Volunteer Services. You are retained as a Sholom Community Alliance volunteer on the assurance that you will observe the requirements stated above. Violation of this agreement may result in termination of your volunteer privileges. Disclosure of any protected health information is a violation by the law not only during the time you volunteer, but at any time after you ve stopped volunteering with Sholom Community Alliance. Information gathered and distributed in relation to the Celebrations of Life program does not fall under the HIPAA requirements. I understand that under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have an obligation to protect the resident s, tenant s and client s protected health information both during and following my volunteering with Sholom Community Alliance. By signing this form, I acknowledge that I have received a copy of HIPAA Your Duty to Protect Residents, Tenants, Clients Protected Health Information ( PHI) pamphlet and that I will follow all confidentiality requirements as outlined in this document. By signing this form, I agree to adhere to all the requirements of HIPAA. By signing this form, I understand that any violation of HIPAA can result in immediate termination of my volunteer privileges. Date: Volunteer Printed Name: Volunteer Signature: Signature of Director of Volunteer Services
Volunteer Code of Ethics Agreement As a Sholom Community Alliance Volunteer I am accountable for the following: 1. I will be responsible for reading and working within the guidelines and policies of the Sholom Volunteer Handbook. 2. I will be in regular attendance, notifying appropriate staff if I am unable to volunteer. If unable to reach appropriate staff, I will leave a message with the receptionist. 3. I will maintain confidentiality of resident/tenant information. 4. I will sign in/out when volunteering. 5. I will wear my name tag only when volunteering. 6. I will be professional in my attitude toward my volunteer duties; to the people I will work with and to the public. 7. I will not solicit any resident/tenant, family member, staff or other volunteer at anytime. 8. I will speak to the Director of Volunteer Services or my staff supervisor immediately regarding dissatisfaction, misunderstandings or any other concerns. Signature of Volunteer Date
BACKGROUND STUDY SHOLOM COMMUNITY ALLIANCE MINNESOSTA DEPARTMENT OF HUMAN SERVICES BACKGROUND STUDY CRIMINAL BACKGROUND CHECK INFORMATION The Minnesota Department of Human Services Background Study Checks are mandatory for prospective employees, contractors, and volunteers who will have direct contact with patients and residents served by Sholom Community Alliance to provide program services. Your privacy rights are outlined in a separate notice entitled Background Study Privacy Notice. Items marked with an asterisk (*) are optional. Criminal background checks are mandatory and are performed before a final offer of employment is made. Failure to accurately complete the information below will disqualify you from consideration for employment. PLEASE CLEARLY PRINT ALL INFORMATION CBC REQUIRED SHW/SHE: HOUSING: HOSPICE: HOME CARE: Requested by: NAME: FIRST FULL MIDDLE LAST IF YOU HAVE BEEN KNOW BY ANY OTHER NAMES IN THE PAST TEN (10) YEARS (i.e. married names,maiden names, etc) PRINT THEM BELOW: 1. 2. I AM AM NOT A CURRENT EMPLOYEE OF SHOLOM COMMUNITY ALLIANCE. GENDER: MALE FEMALE SOCIAL SECURITY NUMBER: MN DRIVERS LICENSE/MN STATE ID (if any)*: TELEPHONE NUMBER*: DATE OF BIRTH: CURRENT ADDRESS: City State Zip PRINT BELOW THE CITIES/STATE/ZIP CODES YOU HAVE LIVED IN DURING THE PAST TEN (10)YEARS: 1. FROM: TO Street Address City State Zip 2. FROM: TO Street Address City State Zip 3. FROM: TO Street Address City State Zip 4. FROM: TO Street Address City State Zip Applicant Signature Date Would You Like A Copy Of The Report To Be Mailed To You No Yes
BACKGROUND STUDY PRIVACY NOTICE MINNESOTA DEPARTMENT OF HEALTH LICENSED FACILITIES SUPPLEMENTAL NURSING SERVICES, EDUCATIONAL PROGRAMS, TEMPORARY EMPLOYMENT AGENCIES, PROFESSIONAL SERVICES AGENCIES Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following: 1. Purpose and intended use of the information: Minnesota Statutes, section 144.057, requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individual who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS. 2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study. 3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics indentified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified. 4. Known consequences that will arise from refusing to supply the requested information: Only items identified as optional may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services. 5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent. 07/2011