Dear Prospective Member,
Welcome to the Nome Volunteer Ambulance Department (NVAD). Your application will be submitted to the NVAD Officers for consideration by the active membership of the department. Once that process is completed and the members vote you in, you are awarded probationary status. As a probationary member you are afforded the opportunity to become involved in most of the activities of membership. This letter will explain some of the responsibilities, obligations and privileges of NVAD membership.
Probationary status is designed to allow you, the members and Officers of the Department the opportunity to get to know you and to decide if the NVAD is right for you, the Department and our community. The hours can be long, and the working environment can and often is emotionally and physically challenging. You will be afforded the opportunity to participate in on-going emergency medical care, to use the skills you have been taught and are allowed to perform by your certification. You will be required to attend regular meetings of the membership and be allowed to participate in membership activities such as social events and community service projects such as the Christmas toy delivery to needy children.
You will be sponsored by an active member who will agree to act as your sponsor. This is your primary contact during your probationary time. Your sponsor has the responsibilities of providing orientation and training to you and providing information to the general membership and officers on your performance. Your questions should be first directed to your sponsor and if they are unable to help you then to the Training Officer.
You may be issued equipment during this time. This equipment is the property of the Department. You are responsible for it. If a problem develops let your sponsor know.
The probationary period is three (3) months.
As a probationary member you are expected to:
1. Cover all scheduled duty times.
2. Run with at least one (1) current EMT.
3. Adhere to all policies and procedures of NVAD.
4. Complete Probationary Member training checklist
Business meetings are generally held on the first Tuesday of each month with training meetings every other Tuesday. The meeting time is 7:00 pm at the Public Safety Building. The monthly duty roster for each month is updated frequently and emailed out to all the members. Members are expected to sign up for at least 8 shifts per month. Each shift is 12 hours in duration. A member who is on duty is required to respond, when notified, to the garage or scene of a 911 call. As a probationary member it is expected that you will run with an ACTIVE member of the department. An EMT and Driver are considered the minimum crew necessary for a run.
Due to the high visibility of our department within the community, all members are expected to act in a professional manner at all times while on duty when interacting with the public that we serve. NVAD strives to maintain a professional working relationship with professionals of other entities assisting in the care of a patient or the control of the scene.
Members are representing the City of Nome and are expected to follow the chain of command when talking to media, law enforcement, or attorneys’ regarding Department Business. Patient confidentiality is critical and you may not divulge any run information to anyone who is not directly related to patient care. When in doubt, don’t say anything and contact the NVAD Chief.
Other items you should be receiving are the following:
New Member Orientation Letter
New Driver Orientation Letter
NVAD Constitution
NVAD Sponsor Checklist
NVAD SOP’s
NVAD Treatment Guidelines and Expanded Scope.
NVAD HIPPA Policy Form
Should you have any questions please don’t hesitate to ask. There is so much more that you need to know that will only come from running with the department. Our job is to seek information and provide quality patient care.
I certainly hope that you will consider joining the Nome Volunteer Ambulance Department. Being an EMT volunteer is high demand with great rewards and it is not for everyone, but I hope to see and meet with you in the near future.
Should you have any questions on the application process, or want to submit an application, please contact the Emergency Services Office at (907) 443-8522
Sincerely,
Vickie Erickson
NVAD Chief
NOME VOLUNTEER AMBULANCE DEPARTMENT
Application for Membership
Name______
Physical Address______
Mailing Address______
Email: ______
Home Phone______Work Phone______Cell Phone:______
DOB ____/____/____ Age______SSN: ______- ____ - ______
Employer______Occupation______
If needed, may we contact you at work? Yes _____ No ______
Do you have a valid Alaska Drivers License? Yes_____ No______License#______
Are you a legal U.S. citizen? Yes____ No____
High School Diploma? Yes ____ No ______GED? Yes _____ No ______
Any College? Some _____ Associates _____ Bachelors ______Masters +______
Are you certified as an ETT/First Responder? Yes____ No____
Are you certified as an EMT? Yes____ No____ Level ______Certification #:______
State in which you are certified______
Are you Nationally Registered ? Yes____ No____ Registration #:______
Do you hold any other EMS certificates or medical training? ______
Location of training:______
Date of training:______
Current license/certifications and expiration date:______
BLS/HCP CPR Certified? Yes______No______Exp. Date:______
Please list any ambulance/rescue affiliation and / or hospital experience, etc. you may have in the EMS field.
______
______
______
Other training or certificates
______
______
______
In case of an emergency contact:
Name______Relation______
Address______
Home Phone______Cell Phone:______Work Phone______
Allergies: ______
Any medical history/conditions we should be aware of in the event of an emergency? ______
Yes / NoHave you been convicted of a violation of a federal or state law, excluding minor traffic violations, in the last five years? / ( ) / ( )
Have you ever been convicted of a violation of federal or state law pertaining to medical practice? / ( ) / ( )
Have you ever been convicted of a violation of federal or state law that pertains to illegal, illicit or prescription drug sales, possession or distribution? / ( ) / ( )
Have you ever been convicted of either a felony or misdemeanor offense involving domestic violence? / ( ) / ( )
Have you within the last 10 years been convicted of either a felony or misdemeanor sex offense? / ( ) / ( )
Have you been convicted of a either a DWI or OMVI in the last 5 years? / ( ) / ( )
Have you ever been treated for drug addiction or alcoholism? / ( ) / ( )
Are you currently on federal or state probation or parole? / ( ) / ( )
I have read and understand the above and certify that the information I have provided is true to the best of my knowledge.
______
Signature of Applicant Date
I give my permission for the NVAD to conduct a background criminal history and criminal conviction records check.
______
Signature of Applicant Date
Requested Sponsor Name:______Requested Sponsor Signature:______
*Applicant should attempt to contact an NVAD member for sponsorship. If unable, one will be assigned.
APPLICANT CHECKLIST: (it is the responsibility of the applicant to complete the following items, PRIOR to submitting application for review.)
o Driver’s License
o EMS Certification
o Background Check
o Sponsor Signature
o BLS/HCP Card (if applicable)
REVIEWING OFFICER’S REMARKS:
Officers have received a copy and verified all of the following prior to submitting volunteer for City insurance approval.
o Driver’s License
o EMS Certification
o Background Check
o Sponsor Signature
o BLS/HCP Card (if applicable)
o Sponsor Assigned
Approved:______Denied:______Remarks:______
______
Officer Signature Title Date
*Only COMPELTED and APPROVED applications shall be signed and approved.
Nome Volunteer Ambulance Department
Policy on Confidentiality and Dissemination of Patient Health Information and Staff and Volunteer Member Verification
Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course of our work. NVAD prohibits the release of any patient information to anyone outside the organization unless required for purposes of treatment, payment, or health care operation, and discussions of Protected Health Information (PHI) within the organization would be limited. Acceptable uses of PHI within the organizations include, but are not limited to, exchange of patient information needed for the treatment of the patient, billing, and other essential health care operations, peer review, internal audits and quality assurance activities.
I understand that NVAD provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of NVAD’s patients. I understand that it is necessary, in the rendering of NVAD services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws.
I agree that I will comply with all confidentiality policies and procedures set in place by NVAD during my entire employment and or association with NVAD. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify the Privacy Officer of NVAD immediately. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my employment or association with NVAD. Upon termination of my employment or association for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. This is not a contract for continued employment or association with NVAD.
I have read and understand all privacy policies and procedures that have been provided to me by NVAD. I agree to abide by all policies or be subject to disciplinary action, which may include verbal or written warning, suspension or termination of employment or association or of any membership with NVAD. This not a contract of employment and does not alter the nature of the existing relationship between NVAD and me.
Signature:______/ Date: ______Printed Name: ______
Updated November 12, 2013