Volunteer Application

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PETERSON HOSPiCE
l121 Broadway
78028
830‐258‐ 7799
FAX 830‐ 258‐ 7009
Kerrvi‖ e,Texas
Volunteer Application
The information on this form will help us to use your particular abilities to the
fullest extent. We appreciate your willingness to volunteer your time.
Name:
Email:
Address:
City:
State:
Zip:
Home Phone:
Cell:
Work:
Educational Background:
Are you a Veteran and if so which branch of service?
Work Experience (Professional or Volunteer):
List churches, clubs, organizations:
Foreign languages you speak or write:
How did you hear about Hospice?
How many hours per week are you interested
volunteering?
preferred days:
Would you be willing to drive as a part of your hospice work and how far?
Have you experienced a major bereavement during the past 12
lf yes, please explain:
Emergency Contact:
Name:
PH 03-15-13
Phone:
months? Yes
No
ln what areas of Hospice would you prefer to work?
(Check allthat apply)
PATIENT CARE
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Patient Visitation
Shopping
Errands
Hobbies
Reading to patient
Making Memories
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tr
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Child Care
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Write Letters
Meal Preparation
Light Housekeeping
Sewing
Floral
Relieving Caregiver
BEREAVEMENT
! Facilitate Groups
tr Visit Families
Phone Calls
OFFICE ASSISTANCE
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Computer Work
Copying/ shredding
Answering Telephone
! Mailings
I Writing Letters
E Sending Birthday Cards
THRIFT SHOP
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Sorting ltems
Helping Customers
fl
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Marking ltems
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ldeas: (List below)
Cleaning, Tidy-up
OTHER ACTIVITIES
f]
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Community Ambassador
Memorial Services
Special Events
By submitting this application, I commit to completing the appropriate training and will be
willing to follow the policies outlined by Peterson Hospice
Signature:
Cleared to Start date:
PH 03-15-13
Date:
Volunteer Coordinator
PETERSON REGIONAL MEDICAL CENTER
PETERSON HOSPICE VOLUNTEER
BACKGROUND CHECK
Application Disclosu rel Release Form
Pursuant to the requirements of section 604(b) of the Fair Credit Report Act6, notice is
hereby given to the undersigned that a Consumer Report (including a criminal
background check and an education check) may be made in connection with the
application for volunteer assignment with Sid Peterson Memorial Hospital / Peterson
Hospice.
I am entitled to know and am hereby advised that the nature and scope of the
investigation will be to obtain applicable information about my previous employment,
criminal background and education.
Notice is also given that in the event that such information has an adverse effect, either
wholly or in part, upon consideration of my application, I am entitled to a copy of the
report from the reporting agency and a statement of consumer rights.
I authorize that a
consumer report, criminal background check, and education check be
done in connection with my application for volunteer assignment.
Today's Date:
Volunteer's Signature:
Volunteer's Printed Name
(as appears on your Social Security Card)
Volunteer's Other Last Names:
Social Security Number:
Date of Birth:
Counties you have resided in for the past five years:
PH 04/08
PETERSON HOSPICE
PATIENT VOLUNTEER
REFERENCE FORM
PLEASE LiS丁 ￢ⅣO(2)REFERENCES FOR YOU AS A HOSPICE PA丁 IENT VOLUNTEER:
2
PHONE#:
DATE CHECKED:
PHONE#:
DATE CHECKED:
COMMENTS:
I
give permission for Volun teer Coordinator to check the above listed references.
Volunteer Signature:
DATE:
Volu nteer Coordinator:
DAttE:
PH 05… 2010
EMPLOYABILITY CONSENT FORM
I understand that the agency will conduct background screening including but not limited to a criminal history
search, a Texas Employee Misconduct Registry [EMR] search, and a search ofthe Texas Nurse Aide Registry
[NAR]. I understand that I cannot be employed or volunteer if the criminal history results identify offenses that
bar employment or if I am listed as unemployable as a result of the Employee Misconduct Registry search or
the Nurse Aide Registry search. I understand that the agency will complete the searches ofthe EMR and the
NAR on an annual basis for unlicensed or volunteer staff with face-to-face patienuclient contact. The EMR
rules are referenced at Title 40, Part 1, Chapter 93 [RULE 593.3] and Chapter 253, Texas Health and Safety
Code, Employee Misconduct Registry.
I understand that if the agency believes that a conviction or other criminal history results may bar my
employment or may be a contraindication to employment that I can be fingerprinted at my own cost and
request that the criminal history results be forwarded to the agency as a way of verifying the accuracy
of my criminal history record.
l, the undersigned, hereby authorize this agency to conduct the background screening.
Signature of Employee/Applicanwolunteer:
Date.
FOR OFFICE USE ONLY[DO NOT WRITEIN THIS SECT10Nl:
(name of authorized agency representative) have conducted or verified that the
background screening has been completed. All results have been reviewed and the individual has been
cleared to work or volunteer.
￨,
Criminal History Search completed on or before
_(date).
_
EMR search completed on
(date) via web
https://emr.dads.state.tx. us/DadsEMRWeb/ or
http://www. dads. state.tx. us/providers/N F/credential in g/sanctions/index.
Employable or
_
Not employable
NAR search completed on
https:〃 emr
cf m
(date)via Web
dads state tx us/DadsEMRWeb/or
http://― dads state tx us/providers/NF/credentia‖ ng/sanctions/index cfm
Listed as NA with certincate#
Not listed as NA [employable/no findings]
Finding of ANE/not employable
09′
01/1l TXHCC
exp
EMPLOYABILITY CONSENT FORⅣ I
NAME:
DATE:
(please print as listed on SS card andior TX DL)
Additional Alias Names used if any including maiden name if applicable:
SSN#
￨,
Date of Birth
have had no prior convictions of any of the offenses listed
below which would bar or potentially bar employment.
(1) an offense under Chapter 19, Penal Code (criminal homicide);
(2) an offense under Chapter 20, Penal Code (kidnapping and unlavdul restraint);
(3) an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children), or
Section 21.11, Penal Code (indecency with a child):
(4) an ofiense under Section 22.011, Penal Code (sexual assault);
(5) an offense under Section 22.02, Penal Code (aggravated assault);
(6) an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
(7) an offense under Section 22.041, Penal Code (abandoning or endangering child);
(8) an offense under Section 22.08, Pe al Code (aiding suicide);
(9) an offense under Section 25.031, Penal Code (agreement to abduct from custody);
(10) an offense under Section 25.08, Penal Code (sale or purchase of a child);
(11) an offense under Section 28.02, Penal Code (arson);
(12) an offense under Section 29.02, Penal Code (robbery);
(13) an offense under Section 29.03, Penal Code (aggravated robbery);
(14) an offense under Section 21.08, Penal Code (indecent exposure);
(15) an offense under Section 21.12, Penal Code (improper relationship betlveen educator and student);
(16) an offense under Section 21.15, Penal Code (improper photography or visual recording);
(17) an offense under Section 22.05, Penal Code (deadly conduct);
(18) an offense under Section 22.021, Penal Code (aggravated sexual assault);
( 19) an offense under Section 22.O7 , Penal Code (terroristic threat);
(20) an offense under Section 33.021, Penal Code (online solicitation of a minor);
(21) an offense under Section 34.02, Penal Code (money laundering);
(22) an offense under Section 35A.02, Penal Code (Medicaid fraud);
(23) an offense under Section 36.06, Penal Code (obstruction or retaliation);
(24) an offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092,
Penal Code (cruelty to non-livestock animals); or
(25) a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an
offense containing elements that are substantially similar to the elements of an offense listed by this
subsection.
A conviction of the following within the last 5 years:
(1) an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A
misdemeanor or as a felony;
(2) an offense under Section 30.02, Penal Code (burglary);
(3) an offense under Chapter 31, Penal Code (theft), that is punishable as a felony;
(4) an offense under Section 32.45, Penal Code (misapplication offiduciary property or property of a
financial institution), that is punishable as a Class A misdemeanor or a felony;
(5) an offense under Section 32.46, Penal Code (securing execution of a document by deception), that
is punishable as a Class A misdemeanor or a felony;
(6) an offense under Section 37 .12, Penal Code (false identification as peace officer); or
(7) an offense under Section 42.O1(a)(7), (8), or (9), Penal Code (disorderly conduct).
09/01/11 TXHCC
Peterson Hospice
Volunteer Acknowledgment
Confidentiality: Peterson Hospice maintains confidentiality of operations, activities, and business affairs of the
Peterson Hospice and the clients according to 1996, Health lnformation Portability and Accountability Act (HIPAA).
Due to the nature of our work, each volunteer will gain, directly or indirectly, sensitive and confidential information
on clients/patients and staff members. The health care professional safeguards the client's right to privacy by
judiciously protecting information of a confidential nature including medical treatment information, diagnosis,
medical records, personal patient information, etc. This information should be shared only with those persons who,
due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for
social conversation or gossip. lf a volunteer is in doubt as to whether or not certain information may be shared,
he/she should consult with his/her supervisor.
Drug Testing Policy: Peterson Hospice conducts 'random/for cause" drug testing on its volunteers. Peterson
Hospice maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs
or alcohol. All volunteers are prohibited from the unlalvful or unauthorized manufacture, distribution, dispensing,
possession or use of a controlled substance or any alcoholic beverages while in the workplace or on Company
paid time. Violation of this policy can result in disciplinary action, up to and including termination of employment. I
acknowledge I have received a copy of the Peterson Hospice's policy on drug testing.
Harassment Policy: Peterson Hospice is committed to providing a work environment that is free from all forms
of discrimination and unlav'rful harassment including sexual harassment. This policy applies to all volunteers
including management personnel. Sexual harassment is any unwelcome sexual advances either explicit or
implicit as a term or condition of employment. lmproper behavior may be verbal, visual, or physical in nature
and/or the creation of a hostile environment. Management will investigate complaints of sexual harassment
promptly, impartially and without fear of retaliation to the volunteer. A volunteer should report the alleged incident
immediately and confidentially to the appropriate manager or Human Resources.
Non Solicitation/lllegal Remuneration: Peterson Hospice does not reimburse or provide incentives lo volunteers,
physicians, durable equipment providers, family or other health professional for patient referrals for hospice
services. Volunteers found in violation of this policy will be subject to discipline up to termination of employment.
Non-Discrimination: Peterson Hospice does not discriminate against clients or volunteers based on race, color,
religion, age, sex, national origin, marital status, or disability.
Abuse, Neglect, and Exploitation: Peterson Hospice volunteers will report suspected abuse, neglect and/or
exploitation to the state departments of the Texas Department of Family and Protective Services, the
Department ofAging and Disability Services, and Peterson Hospice management. Peterson Hospice
volunteers suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be
conducted, and if the investigation validates the claim, the volunteer will be terminated.
Peterson Hospice Policies: I acknowledge that I have read, understand, and will comply with all applicable
Peterson Hospice policies and guidelines.
Volunteer:
Date:
PH 02-2007
Peterson Hos pice/Pathways/Am bassador
Vol unteer Opportu nities
There are many ways volunteers can make a difference in the lives of patients and family members when
there is a life limiting illness:
Hospice Patient Visitation
Hospice is required to have volunteers provide 5% of the care to patients. Many patients need someone
to come in to play games, read to them, write letters, or just visit. Their families need volunteers to provtde
respite care in the home, assist with child care, maybe cook a meal or do light housekeeping, orjust listen
to their concerns.
Pathways Patient Visitation
This is a volunteer based community service program for patients that have a life limiting illness and a
diagnosis of up to two years. Volunteers offer soclal and emotional support to the patients and their
families through regular visitatlon, phone calls, etc.
Peterson Ambassadors
A community outreach program providing activities at various retirement and community centers, as well
as nursing homes, throughout the areas we serve. Volunteers work in teams of two to call bingo; read to
patient groups; sing to patient groups; host welcome receptions for new residents; and other
miscellaneous activities on a monthly basis.
Flower Delivery
Every Tuesday a group of volunteers come together to make floral arrangements and deliver to Hospice
patients. These deliveries give a special message of caring to our patients and provide volunteers a
chance to visit with the patients and their families. New volunteers are always needed.
Peterson Hospice Thrift Store
The Thrift Store is open from 10 until 4 pm Monday through Friday and 10 until 2 pm on Saturday. Work
includes keeping the store stocked, cashiering and keeping the store neat. Volunteers may work in the
back room sorting and pricing donations, on the floor, or at the cash register. There is always something
to do, and we have a good time doing itl
Administrative Assistance
There are many jobs done in the office that utilize volunteers such as answering phones, preparing
admission packets, making copies, writing thank you notes, or helping with special projects.
No One Dies Alone
NODA is a volunteer program that provides a reassuring presence of a volunteer companion to dying
patients who would otherwise be alone. Volunteer companions are scheduled in shifts around the clock to
be present to the dying patients within the last 48 hours of thejr life. This program could be initiated by
Peterson Regional Medical Center staff or Peterson Hospice staff.
Bridging the Gap
A free bereavement program that provides emotional suppo( to children and their parents/ guardians who
have experienced a death of someone signjficant in their life. The 10 week program gives children the
outlet and tools they need to express their grief while helping parents/guardians understand how to
emotionally support the family through loss. Volunteers are trained to be group facilitators for this
program. Support volunteers assist in registering appljcants, serving dinner and preparing supplies.
What does it take to be a Hospice or Pathways Volunteer
1.
Have a desire to make a difference in the lives of those with a terminal or life limiting
illness either through providing support in the Thrift Store, interacting with patients,
volunteering in the community, or helping in the office.
2.
Call Rhonda Richter or Luann Stancil, or come by the Hospice office
al
1121
Broadway (above the Peterson Hospice Thrift store).
3.
Complete training so you are comfortable in your chosen job.
Hospice/Pathwavs Patient Visitation
Patient visitation requires going through a 16 hour training which includes the
philosophy of Hospice, concepts of Hospice and Pathways, stages and care of the
dying, stages of grief, and understanding the importance of patient confidentiality.
Am bassadors
Ambassador volunteers receive 1-2 hours of training.
Thrift Store
Thrift store volunteers receive 1 % hours of training on the philosophy of Hospice,
store policies and procedures as well as onthe-job training.
Floral
Floral volunteers receive 4 hours of training on patient confidentiality and aides for
communicating with the terminal patient'
NODA
'1
NODA volunteers must go through Hospice/Patient visitation training or the hour
NODA training course.
Bridqinq the GaP
Facilitators go through a separate training scheduled as needed'