Phoenix Indian Medical Center Volunteer Application 4212 N. 16 th Street, Phoenix, Arizona Volunteer Services,

Transcription

1 Phoenix Indian Medical Center Volunteer Application 4212 N. 16 th Street, Phoenix, Arizona Volunteer Services, Please Print : 1. Name: 2. Address: 3. Telephone: ( ) 3. Address: 4. Age: of Birth: 5. Contact in case of emergency: Telephone: ( ) 6. Have you done any volunteer work in the past? If yes, where: 7. Why do you wish to volunteer? Job Experience School Credit Comm. Srvs. Other: 8. Please state any physical limitations: 9. List some skills and experience you now have: 10. How many hours per week are you willing to volunteer? 11. What days of the week are most convenient for you? Time available: 8am-12noon 12noon-4pm Other: 12. How long do you plan on volunteering? 13. What department of the hospital would you like to work? Students Only: 14. Name of University/School: 15. Name of Program: 16. s of Rotation/Externship: 17. Students: how many hours do you have to complete for your externship? NAME: Page 1

2 18. Volunteer Service Conditions: (a) The volunteer's service is at no cost to the Indian Health Service or Federal Government. (b) The volunteer performing services, as described in the attached job description for PIMC, is considered a non-paid employee of the Federal Government for the purpose of benefits provided under 5 US Code 8101 for work related injuries or diseases and for purposes of coverage under 42 USC Section 233 and 28 USC Section 1346 (Federal Tort Claims Act). (c) Emergency outpatient treatment for injuries sustained while performing volunteer service will be provided at the Phoenix Indian Medical Center. 19. The volunteer will will not receive the following benefit: (a) Lunch 20. Volunteer will will not be performing patient care. 21. I agree to provide volunteer services to the Phoenix Indian Medical Center as indicated in the attached description of duties. I understand the provisions of this agreement. 22. I agree to adhere to the Phoenix Indian Medical Center Polices and Procedures as provided to me in orientation. (Service Excellence, Infection Control, Emergency Preparedness, Environmental Health & Safety, Privacy Act) 23. I understand either party without advance notification can terminate this agreement. Volunteer Signature Department Chief Volunteer Services Director CEO Office Use: Department Assigned/Supervisor: EHN: s of Stay: Orientation: NEO <61day ID Badge: Security Disk: Computer Access: Status: Day of Week/Time of Day Assigned: Notes: NAME: Page 2

3 Phoenix Indian Medical Center Health Profile Please Print Name: Last First Initial A. Significant Medical History: Enter date of onset, if known. If unknown, enter (X). Diabetes Asthma Deafness Right Ear ( ) Left Ear ( ) Fainting Spells Heart Disease (stroke, heart attack) High Blood Pressure Migraine Headaches Painful or swollen joints Seizures Vision Problems Back pain or injury Allergies B. Women: Are you pregnant now? No ( ) Yes ( ) Due : C. Communicable Disease Profile: Indicate if you have had the following diseases: 1. Measles (7 day measles - hard measles) Yes ( ) No ( ) : 2. Mumps Yes ( ) No ( ) : 3. Rubella (3 day measles called Yes ( ) No ( ) German Measles) : 4. Chicken Pox Yes ( ) No ( ) : Titer : 5. Hepatitis A Yes ( ) No ( ) B : Other: 6. Tuberculosis Yes ( ) No ( ) : Diagnosed NAME: Page 3

4 D. Immunization History: Indicate if you have had shots for the following: 1. Measles (2 doses) Yes ( ) No ( ) s: #1 #2 2. Mumps Yes ( ) No ( ) : 3. Rubella (2 doses) Yes ( ) No ( ) s: #1 #2 4. MMR Titer Positive: Yes ( ) No ( ) : 5. Diphtheria Tetanus (TD) Yes ( ) No ( ) : 6. Influenza Yes ( ) No ( ) : 7. Pneumovax Yes ( ) No ( ) : 8. Heptovax B Yes ( ) No ( ) (3 doses) s: #1 #2 #3 9. Hep B Titer Positive: Yes ( ) No ( ) : 10. Last (PPD) TB Skin Test done : Positive TB Skin Test? Yes ( ) No ( ) If yes, a) did you take medication INH? Yes ( ) No ( ) b) date of last chest x-ray You must attach your copy of: 1. Immunization Record 2. Proof of PPD within last year 3. Titer results (MMR, Hep B, Varicella if you have not had the Chicken Pox) For any immunization questions, please contact the employee health nurse at NAME: Page 4

5 Phoenix Indian Medical Center Privacy Act Briefing What are the Penalties for Privacy Act Violations? Pursuant to the Section of the Privacy Act titled Civil Remedies, the Federal Agency can be required to pay monetary damages if, among other things: 1) The Federal Agency does not review a patient s/employee s request to make a change to his/her record or does not make the change if it is justified; or 2) The Federal Agency does not keep a patient s/employee s record accurate, current or complete, which results in an unfair determination about the patient/employee. Pursuant to section of the Privacy Act titled Criminal Penalties, a Federal employee or contractor/volunteer can be required to pay up to $5,000 if: a) A Federal employee or contractor/volunteer, who knows that certain types of releases of information about a patient/employee are prohibited, willfully discloses the information to person not entitled to receive it. (A violation of this type may result in prosecution and will almost always result in termination from the assigned job.) b) A Federal employee or contract/volunteer who keeps patient/employee information about individual people and does not make public notice of it as required by the Privacy Act of 1974; or c) Any person or organization asks for or receives a copy of an individual s record under false pretenses. Remember: Only medical emergencies require immediate release of information and even then you are responsible for obtaining some assurances of the requestor s identity. When in doubt, deny release until you can look up procedure, or get administrative approval. I agree to safeguard all patient and staff information. I am aware of the regulations and facility security policy designed to ensure the confidentiality of all sensitive information. Improper disclosure of information to anyone not authorized to receive it may result in substantial fines and penalties under the Privacy Act of I understand that my obligation to protect IHS information does not end with the termination of my access to this facility. Name: Signature: : / / NAME: Page 5

6 Phoenix Indian Medical Center Student Volunteer Service Agreement STUDENT SECTION I - Assignment Data 1. Student's Name: 2. Sex: 3. Academic discipline of course training: 4. Educational Institution/Academic Level: 5. Please Attach if your school has Clinical or Learning Objectives 6. Assignment location: 7. Preceptor: 8. Start : End : 9. Proposed hours of week: 10. Institutional Clinical Coordinator Name: 11. Institutional Clinical Coordinator Phone: 12. Institutional Clinical Coordinator STUDENT SECTION II - Educational Institution Agreement I certify that is a student in good standing and the HHS work assignment and scheduled hours of work are approved as appropriate for the course of study of training that this student is pursuing. This student will will not be given credit for this work assignment. I understand that a record of the student's attendance and an evaluation of his/her performance will be provided to this institution when the work assignment is completed. Signature of Program Director Title Educational Institution * A Letter of Good Academic Standing from your Educational Institution Attached can replace Section II. Check if Letter of Good Standing Attached STUDENT SECTION III - Attach Liability Coverage for Student NAME: Page 6

7 STUDENT SECTION IV - Professional Staff Trainees Position Description Part One: Requirements of the Trainee 1. All trainees who rotate at the Phoenix Indian Medical Center and its related clinics must have a Collaborative Agreement signed by their training program and PIMC. This document must be kept on file at the Phoenix Area Indian Health Service Acquisitions Department and PIMC Administration. 2. The trainee must have documentation of being in good standing at their training program. 3. The trainee must fill out the volunteer application for the PIMC and comply with all necessary medical clearances and immunizations. 4. The trainee if not Native American / Alaskan Native nor a Federal Oblige, must complete a statement of interest in serving Native American Communities and dedication to the health and well being of Native People. 5. The trainee must complete the orientation to PIMC before participating in any clinical activities. 6. The trainee must have a signed agreement from the clinical supervisor and the chief of the department authorizing the rotation. 7. The trainee must provide the clinical supervisor for the rotation the learning objectives, the related didactic and clinical expectations and the evaluation form from the trainee s training institution. 8. The trainee must follow all JCAHO Requirements. To include PRINT their NAME and TITLE following their signature on any documentation and not use any Dangerous Abbreviations. 9. Upon completion of the rotation, the trainee will provide PIMC a copy of the final evaluation for the rotation. 10. The trainee will hold harmless PIMC for the didactic or clinical responsibilities of the clinical supervisor. PIMC makes no assurances of the amount or quality of the training experience. The trainee will hold harmless PIMC regarding the final assessment of the trainee s performance by the clinical supervisor. Part Two: Clinical Activities 1. The trainee will be under the direct supervision, at all times by the clinical supervisor while participating in clinical activities at PIMC. 2. The trainee will be cognizant of and sensitive to the cultural, emotional and physical needs of the patient at all times. 3. The trainee will introduce themselves as a professional in their respective discipline to all patients they participate in the care of. The trainee will remove himself or herself from any case whenever a patient requests no trainee participation. 4. All patient care documentation provided by a trainee will be reviewed, corrected if necessary and co-signed by the clinical supervisor, immediately upon completion of the documentation. Part Three: Termination 1. The trainee, clinical supervisory member and the training program acknowledges that PIMC reserves the right to terminate any trainee or rotation without cause and all parties will hold PIMC harmless. I have read and agree to comply with this document: TRAINEE SIGNATURE DATE NAME: Page 7

8 STUDENT SECTION V - Attach Student Evaluation Form STUDENT SECTION VI Attach Statement of Commitment and Desire to work among Native American/Alaskan Native People in our Community. STUDENT SECTION VII - Volunteer Student Agreement I understand the following: 1. I have read the attached statement of duties and agree to perform the assignment as described in Section I. 2. I am to receive no pay for services rendered. 3. I am not considered to be a Federal Employee for any purposes other than for purposes of (1) Federal Tort Claims Act 42 USC Section 233 and 28 USC Section 1346; (2) 5 USC 8101 for work-related injuries and diseases. 4. I am to conduct myself with honesty and integrity in the performance of my duties. 5. I am to consciously safeguard Government business, which is not for public information. 6. This agreement may be terminated at any time by myself, my educational institutional, PIMC, or the Department of Health and Human Services. 7. A record of my attendance and an evaluation of my performance will be provided to me, and my educational institution when my work assignment is completed. Signature of Student STUDENT SECTION VIII - PIMC Agreement The Phoenix Indian Medical Center agrees to accept above named student volunteer. Supervision of the student will be provided and a record of attendance and a written evaluation of the student s performance will be provided to the student, educational institution at the end of this assignment. Department Chief/Supervisor Contact/Questions: Anthony Dekker, D.O. PIMC Director of Medical Education Anthony.dekker@ihs.gov x1895 Office Use: Student in Good Academic Standing Letter of Commitment Student Evaluation Form Attached Liability Coverage for Student Attached Documentation of Immunization/Titers Notes: NAME: Page 8