Volunteer Application

Transcription

1 Campus Assignment Staff Contact PIN Personal Information Volunteer Application Name Address City State Zip Code Phone Cell Education Education completed: High School College Post Grad Are you currently a student? School Course of Study/Major Work/Volunteer Experience Current or most recent employer Duties s of employment Reason for leaving If employed what is your work schedule? Current or most recent Volunteer experience Agency s of Service Reason for leaving Emergency Contact Name Phone Relationship References Please list a professional reference (other than friend or family member) we may contact: Name Phone If you have a friend or family member who is an employee or volunteer for PeaceHealth please list TB App Rec vd Letter UNI/ID Interview TB Active Orientation BG Inactive

2 Locations Preferred For Volunteer Service SHMC RiverBend SHMC University District PeaceHealth Medical Group Family Guest House* Sacred Heart Hospice/Bereavement* Cottage Grove Hospital *adults only Service Areas Preferred Hospitality/Info. Desk Wheelchair Escort Office/Clerical Medical/Patient Unit Gift Shop Waiting Areas Supply/Equip. Delivery Tour Guide Special Projects Quilting Project Knit/Crochet Project Music Courageous Kids Other Availability Days of Week Morning Afternoons Evenings Interests and Goals: Please state briefly what you wish to give or accomplish as a PeaceHealth Volunteer and what you hope to gain from this experience. How did you learn about PeaceHealth Volunteer Services? I understand that: A criminal background check will be required of all applicants age 18 or older. A Tuberculosis Skin Test (PPD) will be required before volunteering. This application is not intended to be a contract or promise of a volunteer position. By submitting this application I am affirming that the statements I have made are true. Name (Please Print) Signature If Applicant is under 18 years of age Parent or Legal Guardian s Signature For staff use only

3 Statement and Agreement Regarding PeaceHealth Information (Confidentiality Agreement) During the course of your work with PeaceHealth, you may develop, use, maintain, or have incidental contact with or access to patient information, employee information and/or business information that is confidential ( PeaceHealth Information ). PeaceHealth Information from any source in any form (including paper records, oral communication, audio recordings, and electronic displays) shall be kept strictly confidential. You may access PeaceHealth Information only if you need to know the specific PeaceHealth Information to perform your job responsibilities. You agree to comply with the notice of privacy practices adopted by PeaceHealth ( Joint Notice of Privacy Practices ) as well as PeaceHealth s policies and procedures to respect and preserve the privacy, security, and confidentiality of PeaceHealth Information. You agree and recognize that you are solely responsible for your own actions relating to protecting the privacy, security, and confidentiality of PeaceHealth Information. This agreement is valid for all positions with access to PeaceHealth information, whether internal or external. Violations of PeaceHealth s policies and procedures may include, but are not limited to: Accessing PeaceHealth Information that is not within the scope of your job or responsibilities to PeaceHealth or otherwise permitted by written policy. Leaving confidential information including but not limited to confidential business information, employee records, patient medical records or charts in an unsecured place or leaving a secured application unattended while signed on to the computer system. Misusing, disclosing without proper authorization, or improperly altering PeaceHealth Information. Disclosing your sign-on code and/or password or using another person s sign-on code and/or password for accessing electronic or computerized records. Discussing PeaceHealth Information in a public place (e.g., elevator or cafeteria) or with persons not authorized to receive such information. Using the incorrect sign-on code and password for a given position, when different sign-on codes exist for multiple positions and/or employers. Violation of PeaceHealth policies and procedures by any user of PeaceHealth Information may constitute grounds for corrective action, up to and including termination of employment or loss of medical staff privileges, in accordance with applicable Medical Staff Bylaws, Rules, and Regulations. Violation of PeaceHealth policies and procedures by volunteers or interns/students may constitute grounds for corrective action in accordance with applicable PeaceHealth or educational institution procedures. Violation of PeaceHealth policies and procedures by third parties, such as temporary staff or vendors, may constitute grounds for corrective action, termination of the user s access, or termination of the contract or other terms of affiliation. Violation of PeaceHealth policies and procedures also may result in civil and/or criminal liabilities and penalties. If you use or disclose a limited data set, which is PeaceHealth Information that has had some but not all identifiers removed, then you specifically agree to only use or disclose the limited data set for research, public health, or health care operations and to comply with PeaceHealth s policy on Deidentification of Protected Health Information and Limited Data Sets. Certain federal and state laws provide you with the right to request access to your personal health information, under specific circumstances. Some users have been provided the right to access their

4 personal health information electronically because of their job responsibilities. If you are one of these users, your right to access your personal health information is subject to the following conditions: You will review only the level of information for which you have electronic information systems access. PeaceHealth will not grant you higher levels of authorization for your review of your personal health information. You may access your remaining health information through your regional health information or medical records department, according to PeaceHealth policy. You will review only your own personal health information or that of your minor child under the age of 13 when legally permitted. You understand that you are not authorized to review the personal health information of your spouse, children age 13 and above, friends, or any other person. Authorization from the patient, written or otherwise, does not permit you to access electronic health information for personal reasons except through means established for that purpose, such as PatientConnection, or through the facility HIM department. Your review will take place under your sign-on password. You will not share or access another person s password to gain greater access. It is your responsibility to talk with your medical provider who may have ordered any diagnostic testing for results interpretation. The information that you review is to be read only, and you cannot and will not alter or delete the information. If you find what you believe to be an error in the electronic medical record, you will submit your request for an amendment to the Health Information Management/Medical Records Department, for review, following PeaceHealth procedures for requesting an amendment to your personal health information. If you have access authorization to any financial data as part of your job responsibilities and you have concerns regarding your financial information, you will not alter or delete any financial data. You will direct all of your inquiries to Patient Financial Services. If you elect to print one or more pages/screens from your personal health information, you will then be responsible for handling your information in a confidential manner. The opportunity to access your personal health information is subject to state and federal laws and PeaceHealth policies and procedures. PeaceHealth retains the right to modify and change this access at any time. I understand that I am responsible for knowing and adhering to the terms of the above statement and agreement as well as PeaceHealth Privacy and Security Policies and the Joint Notice of Privacy Practices adopted by PeaceHealth. I further understand that the obligations set forth in this statement and agreement as well as applicable policies continue beyond the end of my relationship with PeaceHealth. First Name MI Last Name (please print) iliation with PeaceHealth: Employee Medical Staff Member Clinic/Physician Office me: Intern or Student Vendor or Contractor Other Volunteer Signature Signature of Legally Responsible Person (Required if above individual is under age 18) Relationship of Legally Responsible Person to above individual Effective: 4//09

5 Agreement to Provide Volunteer Services for PeaceHealth I understand that I am offering my services to PeaceHealth Oregon Region in the role of a volunteer. I understand, acknowledge and agree to the following: I will not receive or expect any wages, salary, benefits or other compensation/remuneration from PeaceHealth for my volunteer services. I have the responsibility to refuse to perform any tasks that I feel might physically or mentally endanger/injure another or myself. PeaceHealth will provide insurance liability coverage that protects me in the event I am sued because of my designated activities as a volunteer and I am acting within the scope of those designated activities. I need to review my personal insurance policies to determine if those policies will cover me in the event of an injury or occupational disease. PeaceHealth does not provide additional insurance coverage for my protection from injury or occupational disease while I am offering my services as a volunteer. The Department of Volunteer Services reserves the right to separate me from my volunteer status when the action is in the best interest of the volunteer and/or PeaceHealth. Such separation could result from continued absence without notification, inability to work cooperatively with other volunteers or staff, unsatisfactory work, inappropriate interactions involving patients or physicians and/or violation of PeaceHealth policies and regulations. I release PeaceHealth from any and all claims, liability, costs, or other obligations due to any activities I perform that are not the designated tasks for my volunteer assignment. I also release PeaceHealth from any claims, liability, or costs related to any injury I receive while performing the designated activities of my volunteer assignment. Name Signature If applicant is under 18 years of age Parent or Legal Guardian

6 CONSUMER DISCLOSURE AND AUTHORIZATION FORM Disclosure Regarding Background Investigation PeaceHealth (the Company ) may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained in the form of consumer reports and/or investigative consumer reports (commonly known as background reports ). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period. HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight can be contacted by phone at (800) The types of information that may be obtained include, but are not limited to: social security number verifications; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker s compensation claims; bankruptcy filings; educational history verifications (e.g., dates of attendance, degrees obtained); employment history verifications (e.g., dates of employment, salary information, reasons for termination, etc.); personal and professional references checks; professional licensing and certification checks; drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; educational institutions; former employers; personal interviews with sources such as neighbors, friends and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other than as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being evaluated. You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you. Authorization of Background Investigation I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight, Inc., and to the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports, throughout my employment or contract period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of employment or contract for services.

7 I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company. California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company. Applicant Last Name First Middle Social Security No.* of Birth* Present Address City/State/Zip Prior Addresses From: To: From: To: From: To: Driver s License # Applicant Signature * This information will be used only for background screening purposes and will not be taken into consideration in any employment decisions.