Volunteer Application for Clinical & Non-Clinical Staff

VOLUNTEER APPLICATION FOR CLINICAL & NON-CLINICAL STAFF Application date Start date Position:

Name: Last First Middle List all other names used in the last 7 years:

Date of Birth Drivers License Number State issued

Current Address

City State Zip

Address History – Please list the city, state, and zip you have lived or worked in for the past 7 years with approximate dates:

Dates City State Zip

Daytime phone number ( ) Cell Phone number ( ) Email Address

Please provide the school, university or college name (highest level of education received):

School / Institution:

Location (City and State) Attendance Dates:

Degree Major

Name used while attending

of 8 CLINICAL EXPERIENCE: License Type:  RN  RT  CNA  Other  NA

Please check Primary License/certification – state and #:

Expiration Date: Verified by:

 Critical Care  Labor & Delivery  Surgery  Behavioral Health

 Emergency Department  NICU  Outpatient  Dialysis

 Med Surg  Pediatrics  Pediatric ICU  Other – specify:

 ACLS  PALS  ACLS Expires Expires Expires

AVAILABILITY & AFFILIATION Indicate your availability:  Sunday  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday Times of day you may be available Are you registered with a volunteer organization? If yes, select below:  Disaster Healthcare Volunteers  Medical Reserve Corps  Other, specify  California Medical Assistance Team  Disaster Medical Assistance Team

AGE SPECIFIC COMPETENCIES  Newborn/Neonate  Infant  Toddler (birth – 30 days) (30 days – 1 year) (1 – 3 years)  School age children  Adolescents  Preschoolers (5 – 12 years) (12 – 18 years) (3 – 5 years)

CURRENT EMPLOYMENT Current Employer

Years of Employment

Contact information of one reference in current place of practice or employment who can attest to your qualifications to practice or provide service.

NEXT OF KIN & EMERGENCY CONTACT Name, phone number and relationship of two individuals to contact in the event of an emergency. Name Telephone Number Relationship 1. ( )

2. ( )

of 8 PLEASE READ CAREFULLY

DISCLOSURE AND AUTHORIZATION FORM (Name of Hospital), (the “Company”) will procure a consumer report and/or investigative consumer report on you in connection with your employment application. (Name of Company)., or another consumer reporting agency, will obtain the report for the Company. Pre-employ.com, Inc is located at 3655 Meadow View Drive, Redding, Ca. 96002 and can be reached at 800-300-1821.

The report will contain information bearing on your character, general reputation, personal characteristics, and mode of living. The types of information that may be obtained include but are not limited to: social security number verification, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, personal and professional references checks, licensing and certification checks, etc. The information contained in the report will be obtained from private and/or public record sources, including sources identified by you or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances. The nature and scope of any investigative consumer reports that may be requested is explained above. You are nonetheless entitled to request more information about the nature and scope of such reports by submitting a written request to: Compliance Department, P.O. Box 491570, Redding, and Ca. 96049 or faxed to 888-999-3839. The Company is furnishing you with a summary of your rights under the Fair Credit Reporting Act in a form prescribed by the Federal Trade Commission.

ADDITIONAL STATE LAW NOTICES

If you live or are applying for a job in the state of California, Maine or New York, please review these additional notices. CALIFORNIA: You may view the file maintained on you by Pre-employ.com .You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at Pre-employ.com offices in person, during normal business hours and on reasonable notice, or by mail; you may also receive a summary of the file by telephone Pre- employ.com has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. MAINE: You have the right upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such consumer reporting agencies copies of any such investigative consumer reports. NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency.

AUTHORIZATION I have carefully read and understand this Disclosure and Authorization form. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as Pre-employ.com., to the Company. I understand that if the Company hires me, my consent will apply throughout my employment unless I revoke or cancel it by sending a signed letter to Compliance Department, P.O. Box 491570, Redding, Ca. 96049 or faxed to 888-999- 3839. I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed by me before, during or after my employment, if any, may be utilized for the purpose of obtaining consumer reports or investigative consumer reports. By my signature below, I also authorize the disclosure of information concerning my employment history, earnings history, education, motor vehicle history and standing, criminal history, and all other information deemed pertinent by the consumer reporting agency to the agency by the following: past or present employers; learning institutions, including colleges and universities; law enforcement agencies; federal, state and local courts; the military; and, motor vehicle records agencies.

For residents of, or for jobs located in California, Minnesota and Oklahoma only: You will be provided with a free copy of any consumer reports or investigative consumer reports if you check the box below. You may obtain information or copies from the Company’s investigative report file at any time prior to your receipt of such copies, to the extent available, by contacting Compliance Department, P.O. Box 491570, Redding, and Ca. 96049 or by toll free fax 888-999-3839.  I request a free copy of the report.

of 8 Occasionally, Pre-employ.com and/ or its partners send information on identity theft protection, background check information and other related products or services. I DO____ or I DO NOT____ wish to receive this information via email or mail.

Signature Date

Date/Time ADMINISTRATOR/DESIGNEE AUTHORIZATION Emergency Operations Plan has been activated and hospital is unable to meet the immediate patient load.

Valid government-issued photo identification, such as driver’s license or passport and, at least one of the following:

Current picture identification card from a health care organization that clearly identifies professional designation

Current license / certification to practice

Primary Source verification of licensure

Identification individual is a member of DHV, DMAT, MRC, ESAR-VHP, or other recognized state or federal organization or group Identification that the individual has been granted authority by a government entity to provide patient care, treatment and services in disaster circumstances.

Confirmation by a Licensed Independent Practitioners (LIP) currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a LIP during a disaster. Name of (Name of Hospital) staff member: Copies made of documentation and attached Reason documentation not copied:  printer no available  Other I authorize this individual to volunteer Signature of Administrator Date

of 8 Date and time completed - Check Off List For Disaster Completed Application and Background Consent Form Background Check from Pre-Employ.com (Enter names) have access to do this information Online Verification from the State of California or Department of Health www.rn.ca.gov (RN) www.apps.cdph.ca.gov/cvl/ (CNA or CHHA) www.bvnpt.ca.gov (LVN) www.applications.dhs.ca.gov/rhbxray (Radiological Tech) www.arrt.org (Radiological Tech ) www.rbc.ca.gov/ (Respiratory Care Practitioner ) www.nbrc.org/ (National RCP) www.dhs.ca.gov/ps/ls/lfsb/ (Clinical Lab Scientist & Phlebotomy Tech) www.emsa.ca.gov/ (EMT) www.bot.ca.gov/ (Occupational Therapist) www.nbcot.org/ (National OT) www.ptb.ca.gov/ (Physical Therapist) www.bbs.ca.gov/ (Social Worker) www.slpab.ca.gov/ ( Speech/Language Pathologist) www.pharmacy.ca.gov/ (Pharmacist and Pharmacy Techs) www.cdrnet.org/ (Registered Dietitian) www.pac.ca.gov/ (Physician Assistant) www.ncra-usa.org/ (Certified Tumor Registry) www.ardms.org/ (Ultrasound/sonography) www.mbc.ca.gov/ (Physicians) www.abret.org/ (EEG)

PRIVACY, INFORMATION SECURITY AND CONFIDENTIALITY

I understand and acknowledge that in the course of my employment or involvement with (Name of Hospital), or any of its related entities, collectively referred to as (“Organization”), there will be times when I will see, hear, or otherwise have access to confidential and private information such as patient health information, whose privacy and security I must maintain. To that end, I understand and acknowledge that:  I agree to preserve and protect the privacy, confidentiality and security of all confidential information relating to the Organization, its patients, activities and affiliates, in accordance with applicable state and federal laws, including but not limited to the Health Information Portability and Accountability Act (HIPAA), and the Organization’s policies.  I will only access, use or disclose confidential information only in the performance of my duties for the Organization, when required or permitted by law, and disclose information only to persons who have the right to receive that information. When using or disclosing confidential information, I will use or disclose only the minimum information necessary.  The Organization is committed to protecting patient privacy and keeping patient information confidential and secure. I support this obligation during the course of my employment or involvement with the Organization. How I treat, protect, and secure confidential information applies even when I am not at the Organization.  I recognize that posting, transferring, or reproducing patient health information on the internet such as on a social media or networking site or on any electronic or mobile device or via electronic communication methods (e.g. email, text, or instant messaging) without appropriate authorization is not allowed and may compromise the privacy and security of that information and subject me to disciplinary and/or legal action.  If I am provided a user name / log in and password to access any of the Organization’s electronic medical record, billing and financial, or other computer or information systems, I understand that it is my responsibility to follow safe computing guidelines. To this end, I agree not to share my user name / log in and/or password with any other person. I am responsible for any potential breach of confidentiality or privacy resulting from access made to the Organization’s electronic information systems (including mobile devices) using my user name / log in and password. If I believe someone else has used my user name / log in or password, I will immediately report the use to the appropriate information technology department and request a new password. My user name / log in and password constitutes my signature and I will be responsible for all entries made under my user name / log in. I agree to always log off shared workstations and lock personal workstation if left unattended.  I understand that my access to any of the Organization’s electronic information systems is subject to audit in accordance with the Organization’s policies. Page 5 of 8  Under state and federal laws and regulations and the Organization’s policies governing a patient’s right to privacy, unlawful or unauthorized access to, or use or disclose of, patients’ confidential patient information may subject me to disciplinary action up to and including immediate termination from my employment/professional relationship with the Organization, civil fines for which I will be personally responsible, and criminal sanctions.  I agree to report to the Organization’s management, the HIPAA Privacy Officer, and/or HIPAA Security Officer any instance where I suspect that the Organization’s privacy or security policies are being violated or where the security or privacy of the Organization’s confidential or patient information may be compromised. I have read, understand and acknowledge all of the above PRIVACY, INFORMATION SECURITY AND CONFIDENTIALITY; Acknowledgement of Responsibility

Signature Print Name Date

of 8 Attestation of Orientation for Disaster Volunteer

Print Name:

Unit Assignment:

Sign and return this form prior to starting your shift.

By signing below, I attest that I have reviewed the Disaster Volunteer Orientation Packet in its entirety and take responsibility for the information contained therein. If I have any questions regarding the material in the orientation packet, I will seek clarification from the person in charge of my assigned area prior to starting my first shift at (Name of Hospital).

Signature Date

DISASTER VOLUNTEER LIABILITY RELEASE FORM

I, ______, have been approved by (Name of Hospital) for the following: Disaster Volunteer Assignment______All consequences of such above-mentioned selection, including any actions that occur on or off hospital grounds, rest solely with the participant. I understand that (Name of Hospital) is not responsible or liable for any actions taken while participating in the Disaster Volunteer assignment. I agree to hold the hospital harmless from any potential injuries that I may sustain while engaged in any action or activity necessitated by the Disaster Volunteer assignment.

Participant Signature: