Date ______Available for Training: Fall ____ Winter ____ Spring ____ Summer ____

VOLUNTEER APPLICATION

Hospice of the Northwest, an LLC of Skagit Regional Health and United General Hospitalprovides equal opportunity in employment, health care services and all related programs without regard to race, sex, creed, age, religion, color, national origin, disability or any other basis prohibited by law. Applicants may request a reasonable accommodation.Contact Human Resources at SkagitValleyHospital with questions or complaints alleging violations of the Skagit Regional Health equal opportunity policy or to make a request for an accommodation.

Date ______Available for Training: Fall ____ Winter ____ Spring ____ Summer ____

Name ______I like to be called ______

Address______Street City Zip

Phone______

Home Office Cell

E-mail ______NOTE: HOSPICE VOLUNTEERS MUST HAVE E-MAIL & THE ABILITY TO PRINT MICROSOFT WORD OR PDF DOCUMENTS.

Emergency Contact ______

Name Relationship Number(s)

How did you hear about the Hospice Volunteer Program? (check all that apply)

 Newspaper  Radio  Web-site  Flyer  Mailing  Presentation

 Friend/family member had Hospice services  Friend, family, Hospice volunteer or staff member

 Church Bulletin. List church: ______ Other ______

Type(s) of Volunteer Work Desired: (Please review the prior information sheet and check all that apply)

Patient/Family Care  Vigil Team  Patient Engagement Volunteer

 Tuck In Program  Music and Memory  Veterans Inclusion Volunteer

 Office/Administration  Hospice Library  Patient Cheer Volunteer

If you are interested in volunteering in the office, please check off your skills below:

 Filing  Keyboarding  Data Entry/Processing

 Excel Spreadsheets  Microsoft Publisher  Scanning/Photocopying

 Booklet or Binder Assembly  MailingsOther ______

What is your current status?  Student  Employed  Retired  Other: ______

Are you at least 21 years of age:  Yes  No

Have you or a family member served in the military?  Yes  No If so, which branch ______

During which era did you serve? □ Peacekeeping □ Iraq □ Gulf War □ Vietnam □ Cold War

□ Korea □ WWII Would you be interested in serving a patient who is a veteran? □ Yes □ No

Education / School Name / Dates Attended / Major/Course of Study / Degree
High School
College
Employment / Job Title / Company / City/State / Dates: from – to
Volunteer Work / Volunteer Role / Organization / City/State / Dates, from – to

Please list 3 references not related to you by blood or marriage. Applications cannot be processed without this information. Thank you.

Name / E-Mail Address (or Complete Mailing Address if no E-Mail)

What do you hope to receive from this kind of volunteer work?

What qualities (skills, talent, knowledge, and experience) do you feel you can contribute to Hospice, its patients and families?

What do you think is most important when communicating with others?

What are your thoughts and feelings about death?

What are your experiences with death and dying?

What, if any losses have you experienced in the past year (death, divorce, health problems, etc.)?

How has this loss affected you?

Code of Ethics for Volunteers

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me.

Declaration

I hereby certify that the statements made on this application are true and correct to the best of my

knowledge. I understand that, by submitting this application I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the volunteer Code of Ethics above and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Hospice of the Northwest.

______

Applicant Signature Date

Return application to: Erin Long, Volunteer Supervisor, Hospice of the Northwest, 227 Freeway Dr., Suite A, Mount Vernon, WA 98273. Contact Erinat r 360.814.5588

VOLUNTEER APPLICANT REQUIREMENTS

Name ______ Date ______

The following documents, or proof of action, are required in order to volunteer with Hospice of

the Northwest. Please review carefully to be sure that you are willing to comply with all of theserequirements before coming in for your volunteer interview, as they are non-negotiable. Thank you.

Documentation /

Attached

/ Required for Acceptance
SEE NOTE BELOW / Require Annual Updates
Application / * / *
WA Criminal Background Check form / * / *
Confidentiality/Compliance Form / * / *
Availability/Interests/Hobbies/Skills Form / * / *
List and email or addresses of 3 References / *
Copy of Current Driver’s License / * / *
Copy of Current Auto Insurance / * / *
Hospice Photo Identification(Name Tag) / *
Proof of Current Flu Vaccine or Signed Agreement
to Wear a Mask during flu season (Oct – March) / * / *
Proof of MMR and Varicella Blood Immunities / *
Proof of TB Immunity via Quantiferon Gold Test / *

Please bring the enclosed, completed paperwork to your volunteer interview, along with your driver’s license or passport, proof of current automobile insurance with expiration date.

If you have had a flu shot within the past year, please bring documentation of this to your interview. For those who need flu inoculations, information will be given at the interview as to how to obtain these. ALL new volunteers will need TB,MMR and Varicella blood immunity tests and these are offered free of charge.Volunteers may choose to get these immunizations and tests elsewhere at their own cost and must provide documentation of such. ALL prospective volunteers will need to have a Hospice Volunteer name tag made at the Business Office at Skagit Valley Hospital.Information regarding how to get the name tag will be provided at the volunteer interview. Note: All health tests and immunizations should be completed as soon as possible after your volunteer interview and at the very latest, one week before the first day of volunteer training.

HNW CONFIDENTIALITY and COMPLIANCE STATEMENT

It is the policy of HNW to respect the right of confidentiality for all of our patients and employees and to insist that all employees and other members of the workforce, or others with access to patient Confidential Information and Protected Health Information at HNW strictly maintain the confidentiality and integrity of this information. “Confidential Information” includes all facts relating to the patient’s medical care (past, present or future), including oral information, written information and any computerized records or data. “Confidential Information” also includes patient financial information, employee records (medical or otherwise) and any other information of a private or sensitive nature at HNW, including financial and operating information of HNW.

HNW is also committed to operating its facilities and services at all times in compliance with all applicable State and Federal laws, rules and regulations, including those related to patient privacy.

1. I understand that I may only access Confidential Information and Protected Health Information as necessary to perform my specific job-related responsibilities at HNW. I agree not to disclose, communicate, or use any Confidential Information in any manner whatsoever other than in the scope of those services and only to others who have a legitimate need to know any Confidential Information.

2. Examples of breaches of my obligations regarding Confidential Information include:

a)Discussing or revealing Confidential Information and Protected Health Information to friends or family members.

b)Discussing or revealing Confidential Information and Protected Health Information to other employees without a legitimate need to know the information.

c)Discussing or revealing Confidential Information and Protected Health Information in conversations in public places, including reception areas, hallways, elevators, etc.

d)Reading all or any portion of a patient's chart or accessing a patient’s electronic medical record or other clinical data without a legitimate need to do so. Note: computer access to medical records is tracked by HNW as required by HIPAA.

e)Reading all or any portion of an employee’s Confidential Information or accessing electronic or other data without a legitimate need to do so.

f)Inquiring as to the condition or treatment of a patient without a legitimate need to know, as involved in their care.

3. I also acknowledge that electronic computerized patient records and other electronic data create additional risks as to the privacy and security of Confidential Information. I agree to follow all policies and procedures adopted by HNW regarding access to Confidential Information. I acknowledge that my unique computer access codes cannot be shared or delegated for use to anyone and that HNW will deem data accessed or web sites visited using my access code to have been accessed by me.

4. I am familiar with the policies, procedures and guidelines in place at HNW pertaining to the use and disclosure of patient health information and other Confidential Information and Protected Health Information. I will at all times adhere to these guidelines. Approval should first be obtained from the HNW Privacy Officer, or if unavailable, the Release of Information Specialist in the Health Information Management Department before any disclosure of patient information or other Confidential Information in a manner not specifically addressed in the guidelines and policies and procedures of HNW.

5. I understand that the unauthorized disclosure of Protected Health Information and other Confidential Information by me can subject HNW and me to civil and, under certain circumstances, criminal liability under State and Federal law.

6. If I observe or have knowledge of (i) any unauthorized release of Protected Health Information and Confidential Information from HNW or (ii) any practice or incident that I believe to be out of compliance with any law or regulation, I must immediately report this to the HNW Privacy Officer. It is HNW’s policy to encourage open communication between employees and the Compliance Officer and to prohibit any retaliation at HNW facilities in connection with requesting assistance from, or reporting to, the Compliance Officer concerning any suspected improper activities.

7. I have read and agree to strictly adhere to this confidentiality and compliance statement. In the case of HNW employees, violation of my obligations related to these matters will subject me to disciplinary action, which may include immediate dismissal from my employment. I understand that this signed statement will be part of my employment record at HNW. If I have access to Confidential Information through arrangements with HNW other than as an employee, violation of my obligations hereunder may result in the immediate termination of me or my employer’s relationship with HNW, and other sanctions under State and Federal laws.

8. Patient death and termination of volunteer status does not relieve me of my obligation to continue to protect confidential patient health information.

______

Signature Date

______Print Name

PATIENT and FAMILY CARE VOLUNTEER

AVAILABILITY and INTERESTS

Name______VID#______Date______

(please print)

How far are you willing to travel? (check all that apply)Anywhere

WestEast CentralSouth

Anacortes Concrete Mount Vernon Camano Is

LaConner Rockport Sedro Woolley Stanwood

Bayview Day Creek Burlington Conway

Samish Island Hamilton Bow Lk McMurray

Oak Harbor Lyman Edison Arlington

Coupeville Clear Lake Alger Darrington

Langley Big Lake

Guemes Island Newhalem

San Juan Islands

In what setting are you willing to work? Care Facility Private home

When are you willing to visit your patient? (circle all that apply)

8am – noon Noon – 5pm 5 – 10pm

Monday morning afternoon evening

Tuesdaymorningafternoonevening

Wednesdaymorningafternoonevening

Thursdaymorningafternoonevening

Fridaymorningafternoonevening

Saturdaymorningafternoonevening

Sundaymorningafternoonevening

Are you willing to visit on a one-time only basis or serve as a substitute? Yes No

Please list dates you will be unavailable or on vacation: ______

______

Check all of the following interests or experience you have to share with the patients that are assigned to you.

Animals/Pets Cooking Internet Theater Photography

Arts/Crafts Decorating Knitting/Crocheting Politics Travel

Bird Watching Exercise/Sports Movies Religion Woodworking

Books/Reading Games/Cards Music Sewing/Quilting

Cars Gardening Nature/Outdoors Singing

Collecting Genealogy

Are you a veteran? Yes No

Do you play a musical instrument? If so, which one(s) ______

What kinds of jobs or volunteer work have you done in the past that you enjoyed most? ______

______

______

Do you own equipment that can play music for patients? Yes No

Do you own equipment that can play books on tape for patients?Yes No

Do you own equipment that can record patient’s life review stories?Yes No

Are you willing/able to cook or prepare simple meals?Yes No

Are you willing/able to do light household chores?Yes No

Are you willing/able to do light yard work?Yes No

Are you willing/able to be in a home/facility where there are pets?Yes No

Are you willing/able to be in a home/facility where there is smoking?Yes No

Do you speak a foreign language? Yes No

If so, which one(s)______

Please add any other interests, experience or talent, not listed above, that you are willing to share.

______

______