Volunteer Orientation Checklist

*First name:

*Last name:

Email:

I have completed and returned all appropriate forms and tests as further evidence of my understanding, agreement, and commitment:

Standards of Behavior

Confidentiality Agreement

OSHA/Safety Test

Infection Control Test

HIPAA Training Acknowledgement

HIPAA & CMS Compliance Test

Social Media Guidelines

I understand there are additional items I will be required to turn in to complete my volunteer orientation including, but not limited to medical documentation. I shall submit to examinations and annual retesting as necessary as a condition of my volunteer service, which may include:

Skin tests

Chest x-rays

Appropriate laboratory tests

Immunizations

*To the statement above:

I agree I do not agree

*I have read and understand the assignment descriptions for the volunteer assignments I am interested in, and I agree I am able to and willing to perform all duties indicated.

Agree I do not agree

*I have read and understand the Mission, Vision and Values of Crossing Rivers Health.

Agree I do not agree

*I have reviewed the information on Diversity. I understand and agree to be respectful of all staff, volunteers and customers.

Agree I do not agree

*I have reviewed the information on Journey of Excellence and Service Excellence. I understand excellence must be the priority for any health care, and at Crossing Rivers Health we combine the professional service excellence with outstanding personal service.

Agree I do not agree

*I have reviewed the information on Customer Service. I understand great customer service is the number one priority.

Agree I do not agree

*I have read and understand the Guidelines for Effective Communications for All Age Groups.

Agree I do not agree

*I have read and understand the Volunteer Code of Conduct, Volunteer Responsibilities, and Volunteer Policies & Procedures.

Agree I do not agree

*I have read, understand and agree to strictly abide by all rules and policies regarding HIPAA and Confidentiality.

Agree I do not agree

*I have read and understand the proper Infection Control procedures including hand hygiene, standard precautions, isolation categories, and blood borne pathogens.

Agree I do not agree

*I have read and understand the OSHA & Safety Information, including Emergency Conditions & Basic Staff Response, and know my role in case of an emergency.

Agree I do not agree

*I understand that I will be given an identification badge and I am to wear it any time I am on duty, and I agree to return the badge to Volunteer Services when my service is complete.

Agree I do not agree

*I have reviewed the dress code policy and agree I will be in proper attire any time I am on duty.

Agree I do not agree

*I have completed and returned all appropriate forms and tests as further evidence of my understanding, agreement, and commitment: Confidentiality Agreement, OSHA/Safety Test, Infection Control Test, HIPAA Training Acknowledgement, HIPAA & CMS Compliance Tests, Social Media Guidelines, and Standards of Behavior.

Agree I do not agree

*I understand there are additional items I will be required to turn in, including by not limited to medical documentation. I shall submit to examinations and annual retesting as necessary, which may include skin tests, chest x-rays, and appropriate laboratory tests and/or immunizations as a condition of my volunteer service.

Agree I do not agree

*First name:

*Last name:

*Date:

Email:

*I understand that by responding and submitting an answer to any of these questions it is the equivalent of actually “signing” my name to the statement(s) that precede(s) it. My electronic signature will constitute my “original” signature as well as my Acknowledgment and Certification of the applicable statement(s) when used or printed. A signed copy of this form will be maintained in my volunteer file and I can receive a copy at any time from my Volunteer Services office.

Agree I do not agree

Submit