Clinical Volunteer Application and Orientation Packet
YVFWC Student and Volunteer Placement Office
307 South 12th Ave., Suite 4B, Yakima, WA 98902
Contact Information
Elaine Briggs
Health Career Placement Coordinator
Email:
Phone: 509.865.6175 ext. 3419
Fax: 509.453.2363
America Lopez
Health Career Placement Assistant Email: Phone: 509.469.1784, ext. 3419
Fax: 509.453.2363
Table of Content
Welcome and Instructions
Prior to Volunteering – Return the following 6 documents / 9 total pages at least 10 days prior to you start date.
¨ Application
¨ Workers’ Compensation Form
¨ Code of Conduct Acknowledgement*
¨ Confidentiality Acknowledgement*
¨ IS User Policy Acknowledgement*
¨ Annual Mandatory Training Self-Study Post Test
*On your First Day of Service – Complete this information with clinic supervisor
¨ Position Specific Orientation
¨ Volunteer Time Sheet
*At the end of your placement or annually, you will be asked to complete an evaluation.
See Separate Appendix / Training Manual for information related to:
§ Code of Conduct Policy
§ Confidentiality Policy
§ IS User Policy
§ Annual Mandatory Training Self-Study Guide
*Must Read Policy in Appendix Prior to Completing Form
Welcome and Instructions
Welcome to Yakima Valley Farm Workers Clinic (YVFWC). We appreciate your willingness to volunteer to help individuals that may not otherwise have access to services.
The documents in this packet are designed to provide you with a basic understanding of essential policies, procedures and laws applicable to YVFWC. Review and completion of the following documents is required for all volunteers and meets Joint Commission’s accreditation standards for YVFWC and compliance with other State and Federal agency requirements.
At least 10 business days prior to volunteering at the Clinic you will need to submit the following items to YVFWC Student and Volunteer Placement Department. Failure to submit the information below may impact your ability to volunteer.
¨ Application
¨ Workers’ Compensation Form
¨ Code of Conduct Acknowledgement
¨ Confidentiality Acknowledgement
¨ IS User Policy Acknowledgement
¨ Annual Mandatory Training Self-Study Post Test
On your first day of service please read the items below. Clinic leadership will review these items with you to complete your orientation.
§ Site and Position Specific Orientation
§ Volunteer Time Sheet
Please complete & return the following documents to the
YFVWC Health Career Placement Office
at least 10 business days prior to volunteer start date.
Clinical Volunteer Application
Please Clearly Print Information
Last Name: Date: Middle Initial: Phone: First Name: Email:
Current Address: City: State: Zip:
Type of Placement
Profession: Dentist
Hygienist Dental Assistant
Other:
Current Employer Name: Phone:
Certification/Licensure Information
Number: State Issued: Expiration Date: Number: State Issued: Expiration Date: Number: State Issued: Expiration Date:
Other Languages Spoken: Other Skills:
Emergency Contact Information
Name: Relationship: Address: Phone:
Criminal History (RCW 10.97) (ORS 181.555 181.560) – failure to complete may affect results of inquiry
Have you been convicted of a felony or misdemeanor within the last 7 years?
Yes
No
If so, please explain: Alias/Maiden Name:
Date of Birth: SSN: Gender: Race: Mailing Address, if different from above:
I grant permission to YVFWC to verify and obtain information on my employment, school records and license/certification. I hereby release my employers, schools, personal references, and any agencies contacted from any and all liability of damages for providing the information requested. Further, I certify that the above information is true and correct to the best of my knowledge. I understand that misrepresentation or omission of facts is cause for termination or rejection by YVFWC. Placement is contingent upon a satisfactory Criminal History Report and satisfactory references. I understand that
this application does not create a contract of employment. Voluntary placement at YVFWC is at-will and can be terminated at any time at the option of either the agency or myself.
Signature:
Date:
Washington State Workers Compensation
Application for Elective Coverage of Excluded Employment
The following categories of employment are not included within the mandatory coverage of the Industrial Insurance laws of Washington, Title 51 of the Revised Code of Washington. Please indicate the type of coverage elected by placing an “X” in the appropriate box(es).
¨Domestic Servants
¨Gardening, Maintenance, Repair, Etc. in or about the employer’s home not associated with their business
¨Casual Employment
¨Service in return for aid or substance only
¨Minor Children under 18 years of age on a family farm
¨Jockey- Racing
¨Musicians and entertainers
¨Volunteer law enforcement officers (full coverage)(6905) ¨Volunteer Workers (Med Aid only) check one or both boxes below
¨Law Enforcement (6906) Other (6901)
¨Community Improvement Project (6901)
¨Community Service Worker (7203): Project period to ¨Newspaper
¨Insurance agent, broker or solicitors
¨Student volunteers K – 12 only (Med aid only 6901)
xOther (please explain) Clinical Volunteer
I, the undersigned, certify that I am authorized to execute this Application for Elective Coverage on behalf of this business, public entity or nonprofit organization. Benefits in accordance with Title 51 RCW are to be provided to all persons, now or hereafter working under this optional coverage until 30 days after written notice of cancellation of this election has been received by the department. In case of cancellation, I shall post said notice at least 30 days before the effective date in the work area of the affected worker(s) and shall personally notify other affected worker(s). (RCW 51.12.110)
This coverage will not become effective prior to such time as the Department of Labor and Industries receives this signed notification.
Business Name:Yakima Valley Farm Workers Clinic / UBI
600-304-660 / Account ID
Business Address:
PO Box 190 / City State ZIP
Toppenish WA 98948
Applicant’s Name (PLEASE PRINT) / Official Position: VOLUNTEER
Date: / Signature:
Code of Conduct Acknowledgement Form
I certify that I have reviewed the YVFWC Code of Conduct and understand it represents mandatory policies of the organization. I agree to abide by the Code of Conduct and all pertinent policies and procedures. I understand that failure to abide by the Code of Conduct and YVFWC polices will result in disciplinary action, up to and including termination.
Printed Name: ------Date: ------
Signature: ------Site: ------
YVFWC Confidentiality Policy Acknowledgement Form
Yakima Valley Farm Workers Clinic (YVFWC) has a legal and ethical responsibility to safeguard and to protect all confidential information. Confidential information includes patient information, employee information, business information, financial information and other information relating to YVFWC. In the course of my employment and/or association with YVFWC, I understand that I will come into contact with confidential information. Confidential information may be spoken, written or electronic. The purpose of this agreement is to clarify my duties regarding confidential information.
By signing this document I understand and agree to comply with YVFWC Policies & Procedures on Confidentiality and Security
Access, a copy of which I have received for my records (see list of 'Related Documents' on page 2, Appendix). In addition, I:
1. Agree not to disclose confidential information to others who do not have a need-to-know. Need-to-know is defined as that which is necessary for one to adequately perform one's specific job responsibilities as they relate to YVFWC.
2. Agree not access or attempt to access any information, or utilize equipment, other than that which is required to do my job.
3. Agree not to discuss confidential information where others can overhear the conversation e.g., - in hallways, on
elevators, in the lunchroom, at restaurants or social events. I understand that it is not acceptable to discuss any confidential information inside or outside the organization, while on or off duty, even if specific names are not used, other than as permitted in this agreement.
4. Agree not to access any confidential information for any person who does not have a need-to-know.
5. Agree that if I need to access my medical records or that of my dependents that I will do so in accordance with the
Patient Access to Medical Records Policy.
6. I understand that my user name and password are the equivalent of my signature and that I am accountable for all entries and actions recorded during their use.
7. Agree that I will not disclose my user name and password to any person for any reason.
8. Agree not to access any confidential information using someone else's user name and password.
9. Agree not to send or take any confidential information outside YVFWC in any form (including PDAs) without
authorization.
10. Agree not to make any additions, modifications or deletions to any confidential information without authorization.
11. Agree to respect the limitations and usage of the information system network and not to interfere unreasonably with the activity usage of other authorized persons.
12. Understand that my access to all computer systems may be monitored and audited without notice to me.
13. Agree to log out of any computer session opened under my user name and password prior to leaving any computer or
terminal unattended.
14. Understand that if authorized to use Internet and/or email, I will use it only for authorized job responsibilities. Any misuse or abuse (e.g., pornographic material, chain letters, etc.) of these privileges could be grounds for disciplinary action.
15. Agree to respect the ownership of proprietary software. (I will not operate any unauthorized software on YVFWC computers or make unauthorized copies of any software for my own use).
16. Understand that confidential papers should be picked up as soon as possible from copiers, mail boxes, fax machines,
printers and other publicly accessible locations. Confidential papers, reports, and computer printouts should be kept in a secure place. When they are no longer needed, confidential papers should be deposited in the document destruction bins to be destroyed.
17. Understand that my obligation under this agreement will continue after my termination of employment and/or
Association with YVFWC and that my privileges are subject to periodic review, revision, renewal and termination.
18. Agree to notify my supervisor immediately of any unauthorized access or use of confidential information or of violation by anyone of any of the rules above.
19. Agree and acknowledge that any invention(s),trade secrets or work(s) I create, alone or with others, within the scope of my employment duties shall be considered "works made for hire" under copyright law and shall be owned by YVFWC. I assign PMS all of my rights in any and all inventions and works created by me, alone or with others, within the scope of my employment. I will not disclose, directly or indirectly, any such works or inventions except to the extent necessary in the ordinary course of fulfilling my YVFWC job duties.
I understand that violation of this agreement may result in the following:
a. Denial of access to YVFWC computer systems;
b. Disciplinary action as stated in YVFWC Policies and Procedures and the Employee Handbook up to and including
termination;
c. Penalties under State and Federal laws and regulations;
d. Denial of privileges to practice professionally at YVFWC facilities and/or denial of entry into those facilities;
e. Any combination of the above.
Printed Name: ______Signature: ______Date: ______
Information Systems (IS) User Policy & Electronic Security Policies
Acknowledgement Form
I have read all of the Yakima Valley Farm Workers Clinic electronic information security and information services user policies and agree to abide by them. I understand that violation of any of the above policies may result in revocation of my access to computer services and/or sanctions including civil penalties and termination of employment or placement with Yakima Valley Farm Workers Clinic.
Printed Name: Title:
Department: Clinic/Site:
Signature: Date:
Please check one: Employee
Student
Volunteer
Other
Effective Date: implemented 09/2006; 01/2010; 12/2011; renewed 09/2012
Drafter: D. Tschauner – Director of Information Services
Approval Party: D. Tschauner – Director of Information Services
Related Documents: IS User Policy; IS Electronic Access Control Policy; IS Electronic Audit Controls Policy; IS
Electronic Mail Integrity Policy; IS Electronic Security Awareness Training Policy; IS Electronic Security Incident Response and Reporting Policy; IS Information Access Management Policy; IS Login Request Form; IS Transmission Security Policy; IS Workforce Security Policy; IS Workstation Use Policy.
[Please Print]
YVFWC 2013 Annual Training Competency Post-Test
First Name: MI: Last: Worksite: Department:
Your Position: ¨ Volunteer Licensed Provider ¨Visiting Medical Resident ¨Student ¨ Volunteer ¨Temp./Contract Worker
I understand I am accountable to apply the content appropriately as I perform my duties.
Your Signature:
In the multiple choice sections, please circle the correct answers.
YVFWC Mission, Vision Values
1. The health of one person is the health of
a. The world b. Humanity c. Mankind
d. All children
2. Which of the following is part of our values?
a. We will fight for just
treatment for all individuals
b. We will let joy in
c. We will consistently trust
one another to work for the
common good
d. All of the above
Reporting Concerns
3. Employees will be expected to report problems to appropriate leaders and they
are encouraged to complete the
QMA incident form.
a. True
b. False
Adverse Events
4. An “adverse event” is an undesired outcome or occurence not expected within the normal course of care or treatment, disease process, condition of the patient or delivery of services.
a. True
b. False
5. Only providers are responsible to report all adverse events, incidents, and near misses
a. True
b. False
Cultural Sensitivity and
Workplace Diversity
6. YVFWC defines cultural
competence as:
a. Knowledge
b. Skills
c. Attitudes
d. All of the above
7. Cultural competency is the
and of a
system to value the importance
of culture in the delivery of
services to all segments of the
population.
a.
b.
Unlawful Harassment
8. If you feel you are being harassed, you should do the following:
a. Document each incident
b. Report harassment to
your Human Resources
Representative, the Clinic
Administrator or Program
Director
c. Expect that privacy will be
maintained
d. All of the above
Workplace Violence
9. List 2 ways to prevent workplace violence:
a.
b.
10. List 2 early warning signs of violence:
a.
b.