CHAMPAIGN COUNTY NURSING HOME VOLUNTEER INFORMATION FORM

Transcription

1 CHAMPAIGN COUNTY NURSING HOME VOLUNTEER INFORMATION FORM If you are required to perform COURT DIRECTED COMMUNITY SERVICE hours please contact the Director of Environmental Services. You cannot volunteer at CCNH if you have been convicted of a felony. Date: Birthdate: / / Social Security Number - - Name (Last) (First) (Middle) Address (Number & Street) (City) (State) (ZIP) Race White American Indian/Alaskan Native Black/ African America Unknown Native Hawaiian or Other Pacific Islander Asian Best phone Second Phone Are you? Employed Unemployed Student Retired Volunteer Experience Community Affiliations Specials skills or talents you offer How did you learn about us? If your hours are required, please explain RESPONSIBLE PERSON(S) TO BE CONTACTED IN CASE OF ILLNESS OR EMERGENCY: Name Address Phone: 2nd Phone: Relationship PERSONAL REFERENCE (OTHER THAN FAMILY MEMBERS) Name Address Phone Known how long?

2 Do you have any health problems or limitations that would restrict your ability to work with our residents? No Yes (Please list) A two-step TB test is required initially with a one-step TB test required annually thereafter. This TB test is required to volunteer at CCNH. Results of these tests will be kept in the volunteer office. I hereby give CCNH permission to check any references listed above. I hereby authorize the release of any medical data relevant to the position of volunteer at CCNH and hereby release CCNH and all persons from any liability due to furnishing such information. I hereby affirm that the information provided on this form is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration as a volunteer and may be justification for dismissal if discovered at a later date. I hereby understand that ALL information on ALL residents will be kept CONFIDENTIAL. I hereby acknowledge that I have received a copy of the Volunteer Handbook and that I, and others I might be responsible for, will have read and understood it completely. There will be consideration of dismissal if any volunteer fails to comply with the volunteer handbook. Signature Date PHOTO RELEASE I authorize CCNH to photograph and use pictures of me for nursing home interests. I waive all future claims against the nursing home resulting from the use of these photographs. I also understand that I may terminate this agreement at a future date if I feel it necessary. YES NO COMMENTS:

3 Tell me about yourself. What would you do if you had nothing to do? Share some of the most satisfying things you ve done in the past few years. Relate how you think we can help you with the volunteer experience that you desire. Tell about the kind of things you find frustrating or things to avoid. What skills, personal attributes or best qualities do you want me to know about? In your life, who do you want to be in charge of you? Why do you want to volunteer at Champaign County Nursing Home? Please list your availability. Are you willing to make a commitment of a minimum of three months/six months?

4 Champaign County Nursing Home HIPAA Privacy Policy CCNH staff and management strive to comply with the Health Insurance Portability and Accountability Act (HIPAA) to protect our resident s medical privacy. We strive to comply with HIPAA guidelines by appropriately maintaining our resident information and billing processes in compliance with national standards. Our staff has been trained to protect the confidentiality of our resident s private health information. Personal information about a resident may only be released with permission of the resident, or the resident s health care power of attorney to only those specified, except where mandated by law. Summary of the HIPAA rules: 1. It sets boundaries on the use and release of health records. 2. It establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information. 3. It holds violators accountable, with civil and criminal penalties that can be imposed if our resident s privacy rights are violated. 4. It strikes a balance when public responsibility requires disclosure of some forms of data for example, to protect public health. 5. For our residents, it means being able to make informed choices when seeking care and reimbursement for care based on how personal health information may be used. 6. It enables our residents to find out how their information may be used and what disclosures of their information have been made. 7. It generally limits release of information to the reasonable minimum needed for the purpose of disclosure. 8. It gives the residents the right to examine and obtain a copy of their own health records and request corrections. If you have questions regarding our HIPAA privacy policies, please contact our HIPAA Compliance Officer. (Volunteer to keep this page)

5 CCNH Volunteer HIPAA Compliance Signature Form Volunteer Name Date Printed My Commitment to Compliance: I have read and understand the CCNH Volunteer HIPAA (Privacy Rule) Compliance information. I agree to do all I can, within my area of responsibility to maintain up-to-date knowledge about federal and state laws and program requirements. I will comply with these requirements to the best of my ability, and to immediately let the Compliance Officer know if there is any area where I feel the facility is not in compliance with these laws and program requirements. The policy is a simple, yet powerful four-step process: Keep up-to-date; Educate; Comply; and Audit/Correct. We desire that all of our volunteers are particularly cognizant of the fact that Personal Medical Information must be treated with the utmost attention, accuracy, honesty and integrity. We seek to educate and carry out these policies with all our employees and volunteers, managers, clinicians, and where appropriate, contractors and other agents. By signing this form, I agree with the CCNH policy and will do all I can to comply with all regulatory laws pertaining to Personal Medical Information. I understand that the facility has an open door policy and that I may discuss any problems I feel may occur with PHI without worry of recourse with my supervisor or other supervisors. Signature of Volunteer Signature of Compliance Officer