Volunteer Handbook - Roper St. Francis Healthcare

Roper St. Francis HealthcareVolunteer HandbookHealing all people with compassion,faith and excellence.

General GuidelinesThe application process includes:• Acceptance: Personal interview to matching our needs with your interests.• Orientation & Tour: Small group orientations are scheduled on a frequent basis. Review thehandbook before orientation.• Application & paperwork: We are required to have a completed file on each volunteer. Allforms should be returned before you begin service. Volunteer service depends on satisfactoryreference letter, background screen and health screen.• Health Screening: Review of health records and immunization status by the Employee Healthstaff. Two step TB tests are required. Your TB (or PPD) test is done and then read in 48 – 72hours. Your TB test is not complete if it is not read, so schedule testing accordingly. Bringrecords of immunizations and any TB test within the last three months. If you do not havecomplete immunization records, the nurse will draw blood to check your immune status.Volunteers under the age of 18 must provide their own proof of immunity. You do not need anappointment but check office hours at your facility below. Report to the nurse with yourcompleted health forms and say “I am a new volunteer and need my health screening.”Employee Health Office HoursRoper Employee Health Office (724-2131): Weekdays, 7:30 a.m. – 3:30 pmBon Secours St. Francis Health Office (402-1155): Monday & Thursday, 7:30 am – 3:30 p.m.Important! Teens must have parent’s signature on the health form.• Note: Obtain permission note from your physician for serious medical conditions effectingplacement.• Letter of Recommendation: Ask someone who knows you well (not a family member) to writea brief letter recommending that we accept you into the program.• Background Check: A HirEase Background Check will be performed at an expense to thehospital. Honesty is important as you complete your application form.• Starting Service: Let your volunteer coordinator know that you have completed healthscreening and paperwork and schedule your first shift. A skills checklist should be completedand returned to your file anytime you begin in a new work area to make sure you are properlyand safely trained in that area.Dress Code• Professional & Identified: It is important that you are clean, neat and well pressed andidentified as a volunteer while on duty. Don’t wear shorts, jeans, spandex tights,sweatpants or mini skirts on duty. Avoid chewing gum and eating in customer serviceareas.• Nametags: Nametags will be provided and for security reasons should be returned if/whenyou leave our volunteer services.• Uniform options: Uniforms depend on the area you serve so talk to your coordinator.Options include traditional salmon smocks, red cobbler aprons and gray polo shirts withsolid color slacks.• Shoes: Footwear should be comfortable, safe, quiet and clean with tied laces. Avoid opentoes in clinical areas.• Scents: Avoid perfume and scented after-shave products on your days of service, aspatients may be sensitive to strong fragrances.2

• Jewelry: Protect yourself and our patients by avoiding large dangling pieces of jewelry.• Hair: Hair should be groomed with long hair tied away from the face in clinical areas.Sign in: You are responsible for logging your arrival and departure in the Volunteer Sign in book.Record hours daily, rounding numbers to the next 15 minutes. If you have completed requiredservice hours please note completion on your last shift and return your badge.Personal belongings: The hospital cannot be responsible for personal property. Don’t bringvaluables to work with you.Record your Volunteer Hours each time!BenefitsMeals: One meal is provided to volunteers working a full volunteer shift of 3 to 4 hours. Thepurpose is to take care of us while we are on duty and we need to take care not to abuse thisbenefit. As food expenses rise there are facility specific guidelines that will be discussed at yourorientation.• Wear your proper uniform and nametag while on duty so you are identified to the cashier.• Do not take extra food with the intention of taking it home with you and try not to makefrequent return trips for items.• Keep a mental goal of spending $5 - $6. On occasion you may go slightly higher or lowerthat this.• Breakfast is such a good deal that some volunteers pay for breakfast and then enjoy a freelunch.• Remember to thank the food service employees!Parking: Free parking is available to volunteers but our goal is to leave the most convenientparking for our patients. Current options will be discussed during your facility tour.Employee events: Volunteers are welcome at employee events throughout the year. TheVolunteer Department hosts an annual spring Volunteer Awards luncheon for active volunteers andteen volunteers are recognized at summer’s end. You are encouraged to attend quarterly “CEOForums.”Health Benefits: Annual TB tests are required and provided. It is your responsibility to report to theEmployee Health Office on an annual basis. Free flu shots are available to active volunteersduring flu season.Advantage Membership: “Advantage” is a membership program for seniors 55 and older withmany benefits. The membership fee is waived for Volunteers. Forms are available at the FrontDesk or call 724-2489 to register. Note on the application that you are a hospital volunteer.Absences: Patients and staff depend on you. Report to work on time for your scheduled shift. Insome cases another volunteer may be waiting for you to relieve them. If you know in advance thatyou will be absent please let the staff in your work area and your volunteer coordinator knows.When possible arrange to exchange shifts with another volunteer trained in your area. Forunexpected absences call the Volunteer Office and your work area. Never feel guilty aboutabsences due to illness. Your health is most important to us. You are protecting our patients andstaff by not reporting to work with any infectious condition or fever.Inactive Status: Life changes. Let us know if you are not able to continue as planned or becomedissatisfied for any reason with your assignment. Volunteers inactive without prior notice orexplanation for one month will be taken off the active volunteer roster in order to keep our recordsaccurate.3

Gifts & gratuities: Volunteers may not accept gifts of cash from patients.Difficult situations and abrasive callersDifficult situations frequently arise in healthcare where patients andtheir families are under a lot of stress. We cannot solve everyone’sproblems but we want them to know we care and to steer them inthe right direction for the help they need. If a customer is unhappy,stay calm, find out what he or she is upset about and ask yoursupervisor for the correct method of referral. Remember they arenot upset with you! You happened to be their first point of contact.Our patient representatives are experts in problem solving as well as Notary, Ombudsmen and canassist with Living Wills.Patient Representative OfficesRoper Hospital: 724-2965 or 2964Bon Secours St. Francis Hospital: 402-1194The Right Thing to DoRoper St. Francis Healthcare has built a reputation for high ethical standards and good citizenship.Our reputation is one of our most precious assets and must be protected every day.Our “code of conduct” is a reflection of our commitment to the highest standards of business andethical behavior. We believe that the best way to fulfill our mission is for all employees andvolunteers to be honest, ethical, and fair in business practices and personal behavior. Thiscommitment includes complying with all applicable laws and regulations in all areas including:Patient Care and Confidentiality Equal Employment and Workplace Behavior.Conflict of InterestAdmissions & referralsFinance and BillingSafeguarding Property and TechnologyMedia Inquiries and Advertising SafetyRelations with Government Officials and Regulatory AgenciesIn cases where you need additional guidance on an ethics related issue or you simply feelsomething isn’t being done “right or fairly”, you should seek the advice of your supervisor or yourvolunteer coordinator. If you need additional help you may contact the Human Resources, LegalServices or the Corporate Compliance Office. If you are uncomfortable dealing directly with theseoffices you may call the Compliance Help Line at 1–800-597-3386.Sensitivity & DiversityAs members of the Roper St. Francis Healthcare Volunteer Department wewelcome and care for all of our patients and visitors without regard to age,race, sex, color, religion or national origin. It is just as important that we usethis same graciousness and sensitivity in the way we treat our coworkersand fellow volunteers.We hear the word “diversity” a lot lately. What does it mean to us ashealthcare volunteers? Most definitions describe the differences between groups or individuals.Differences may include gender, cultural, spiritual, biological/physical, social, environmental,moral, ethical, economical, educational, political, and ethnical differences. People are not alikeand we must acknowledge that.Life would be boring if we were all the same. Diversity can range from slight differences, suchas those within family members, to major differences such as those between nations, religions,and geographical locations. All of these diversities affect healthcare practices and beliefs.We believe in creating a healing environment and workplace that respects and includes4

differences, recognizes the unique contributions that individuals have to offer and makes themost of the potential of all employees and volunteers as well as making our patients feelwelcome and comfortable.We are fortunate to have volunteers both men and women, from 14 - 95, with fascinatingcultural backgrounds, students and former heads of companies. We have quiet folk who workin supportive roles as the characters who keep us all smiling. Diversity is part of the beauty ofour group.Keeping this in mind, we should be mindful of what we say and how we act. Expressions thatseemed acceptable when and where we grew up may not be now. Our behavior is a directreflection of the Volunteer Services Department and our intent as volunteers is to support andadd joy to the lives of our patients and co-workers. Times change and some of this can beconfusing. If you have any questions about diversity please feel free to ask for moreinformation. Our Human Resources staff is always willing to help us “do the right thing.”Confidentially & HIPAAThe privacy of our patients must be protected at all times. Medical records are by law, confidentialand not for public knowledge. Picture yourself as the fierce protestor of our patient’s privacy.HIPAA stands for Health Insurance Portability and Accountability Act a part of the Social securityact that was signed into law in 1996 and enacted in 2003. HIPAA was put into place to improvehealthcare systems by standardizing electronic data exchange and to protect the security andprivacy of information.The Privacy Section of this law protects an individual’s personal health information and holdshealthcare workers and volunteers accountable for violations with heavy fines.Patients will be given information about their rights on admission. At this time they can evendecide that they want to be completely private and in this case their name may be completely leftout of our printed and computer directories. This means we couldn’t even tell their family membersthat they are here. Other changes you will notice in the hospital is that we no longer use sign insheets where you can see who has signed in earlier that day or directories on walls listing patientsprogress.Important things to remember:• Most confidentiality errors are made by good people trying to do the right thing. Sincevolunteers are very caring people by nature we need to be extra careful.• Only use medical and personal information that you need to do your job. Ask yourself “do Ineed to know that to do my job?”• Protect patient information from view by visitors, other volunteers and staff. Tilt computerscreens away from visitors. Don’t leave patient information lying out in the open. Do not usepapers with patient names on it to make scratch pads.• Anything you learn about your patient is private and should not leave the hospital. We are theiradvocate and protectors.• Do not discuss patient information in public areas – elevators, cafeterias and lounges.• Dispose of all paper with patient information on it when you are finished using it. If you useconfidential information in your job ask your coordinator for the closest shred bin to your area.A ten-minute video will help clarify these issues. If you have any question on this important topicplease talk to your volunteer coordinator.You are responsible for keeping what you learn about your patients private.5

MediaIf the media (TV, radio, newspapers etc.) approaches you refer them immediately to the MarketingDepartment at 720-5755 or the Administrative Offices. Do not answer questions or makecomments. As volunteers we can never know all sides of a story.NewsletterThe “Volunteer’s Voice” is issued monthly and has news for all RoperSt. Francis Healthcare Volunteers. Contact your coordinator with news orsuggestions. Things change and departments relocate frequently. Ourcustomers depend on us for current information so please read the newsletter!Check employee and volunteer bulletin board to stay current with activities.Our Journey to ExcellenceBoth Roper Hospital and Bon Secours St. Francis Hospital have long histories in the Lowcountry.We have been voted the “Best Place to Work” and consistently rank high in patient satisfactionsurveys. Roper St. Francis Healthcare began a Journey to Excellence in 2005. The Journey toExcellence represented our renewed commitment to service and operational excellence. This isan ongoing process dedicated to developing new and innovative ways to provide the very bestpatient care. We hope that you see evidence of some of the positive changes that have takenplace.We revised our mission statement to eight meaningful words:“Healing all people with compassion, faith and excellence.”Join us on our Journey to Excellence. Read and sign the Standards of Behavior.Some of the ways volunteers can make a difference are by:• Greeting each other with a smile.• Offering to help people who are lost by walking them to their destination.• Pick up paper from the floor.• Not taking part in gossip.• Support our co-workers who might be going through a difficult time.• Don’t judge people by their appearance, status, weight, etc.• Be aware of our prejudices and don’t let them influence the care we give.• Be aware of people in need and know where to refer them for help.• Welcome patients to our facilities and thank them for choosing Roper St. Francis Healthcare.• Respect privacy by knocking on patient’s doors before entering.You will hear the staff using the following steps in dealing with patients and customers. It can bemodified for most volunteer roles.A: Acknowledge the patientI: Introduce yourselfD: Duration – how long will the task or procedure lastE: Explain what you are doingT: Thank them for choosing Roper St. Francis Healthcare.Commonly used hospital abbreviations or symbols:NP0: Nothing by MouthSTOP: Call don’t fall!Teardrop: A blue teardrop on the door symbolizes a stillborn or miscarriage.6

Age Appropriate CarePart of the pleasure of volunteer work in a hospital is that it brings us into contact with people of allages. Here are tips for relating to people of different age groups in a safely and appropriately.Neonates (birth to 28 days): Neonates are dependent on others for all their needs.Never leave a baby unattended.Children: Safety is very important when caring for children. Keep side rails up andmake sure toys do not have removable pieces that could cause choking. Keepanything harmful out of reach. Reduce overwhelming stimulation and speak to a childbefore you touch them. Encourage parents to be involved in care. Use play to helpwith explanations. Favorite toys may provide security and comfort. With olderchildren demonstrate and explain everything before you do it and allow them toparticipate as much as possible in their own care.Adolescents (12 – 18 years): Provide privacy and promote independence.Adults: Allow adults to make choices and encourage as much self-care as possibleOlder adults (over 65 years): Keep the environment safe. Side rails should be raised, the bedkept in a low position with the wheels locked. The room may need to be warmer – offer extrablankets.Lost & Found: Found items should be turned in to Lost & Found promptly. If a caller has aquestion about an item transfer them to the appropriate number. If a purse or wallet is turned intoyou do not open it since it may have been robbed already. Report unidentified object.Roper Hospital - Security Office - extension 2045Bon Secours St. Francis Hospital - Support Services (back hallway) - extension 1176Telephone UseOur voice on the phone represents Roper St. Francis Healthcare and it isimportant we greet our callers with an alert and friendly voice tending to theirneeds quickly and efficiently. Keep in mind that our callers are oftencontacting us under stressful situations when a family member is ill. We play avery important role calling for tact and courtesy.• Be friendly and accurate. Answer promptly and with a smile in yourvoice. Take messages accurately.• Identify yourself and location: Example “3 rd Floor Nurses Station, Barbara, Volunteer,may I help you?”• Outside line: Dial “9”• Operator: Dial “0”• Emergencies: 2911• Transferring: 4 numbers are needed to transfer a call in-house. You add a “2” to makefour digits to transfer to a patient’s room. For example, transfer to extension 2118 for Room118. When you transfer a caller tell them what you are doing. Example “That number is____, please hold while I transfer your call.”• HealthLine: RSFH Customer service line at 402-2273. HealthLine operators are happy toregister callers for RSFH programs, direct them to a physician and answer questions aboutthe hospitalRoper Hospital:Patients dial “5” to get an outside line from their rooms. The prefix for calls in this facility is: 724.Bon Secours St. Francis Hospital:Patients dial 9 to get an outside line. The prefix for calls to this facility is 402.7

2911 is the hospital emergency numberWheelchair transportation: Volunteers may transport and discharge wheelchair patients who donot require special assistance keeping these rules in mind:• Wash your hands. Identify the patient. Check to see if the patient’s chart is to accompanythe patient.♦ Discharges: The Nursing staff needs to completely discharge a patient making sure theyhave all their instructions and prescriptions. If the patient needs assistance the nursingstaff needs to help the patient into the wheelchair. The bed should be in a low position withthe wheelchair next to the bed facing the head of the bed.♦ Use good body mechanics. Do not support a patient's weight.♦ To collapse a wheelchair, grab the seat and pull up; to open, pullhandles apart.♦ Patients in gowns should be covered around the legs with ablanket or sheet. Make sure it does not drag on the ground. Coverthe seat of the wheelchair before a patient in a gown sits down.♦ Before you let your patient be seated - push the footrests back, setthe brake and grip the handles firmly. Position the patient’s feet in the footrests and advisehim/her to sit back before releasing the brake.♦ Stay to the right in corridors using caution at intersections. Use overhead mirrors to checkfor traffic. Back into elevators.♦ Never leave a patient in a wheelchair unattended.♦ Before you let your patient get up, set the brake and raise the footrests. Have a firm grip onthe handles.♦ Don’t push a stretcher or patients with IV’s without an employee unless you have receivedspecial training.Health ServicesThe Employee Health Nurse will review your immunization history so bring anyimmunization records with you. Students should bring their school healthrecords. In the absence of records a laboratory “titer” will be drawn to confirmthat you are immune to measles, mumps, rubella and chickenpox. Plan yourHealth Office visit for between 10 am - 2 pm when possible. We are unable tooffer immunizations (other than the required TB test) to minors.TB tests (PPD) are required when you start and annually and are done in theEmployee Health Office. The second test is scheduled for 1 – 3 weeks after thefirst. Each time you need to return 2 – 4 days after to have the test read.If you have had past positive skin tests the staff will review health screening questions with youand repeat this annually. A past positive test will require a recent (within 3 months) chest x-ray.Employee Health OfficesRoper Hospital Bon Secours St. Francis Hospital Roper Berkeley Day(Worksite Partners building) Human Resources Office Check posted schedule.Phone 724-2131 Phone 402-1155*Weekdays, 7:30 a.m. to 3:30 p.m. *Monday & Thursday, 7:30 a.m. to 3:30 p.m.*try to go between 10 a.m. – 2 p.m. to allow the staff to complete their work before closing.Hepatitis B: Volunteers who will have direct contact with in-patients should discuss Hepatitis Bvaccine with the Employee Health Nurse. We are unable to provide the Hepatitis B vaccine forminors and they should discuss the need with their family physician.8

After absences for serious illness or surgery you should clear your return to service with yourmedical doctor.Juniors under the age of 18 need a parent’s signature before their TB test.On The Job Injury: Stay safe! Should any injury occur during your working hours notify yoursupervisor and the Volunteer Coordinator. We must complete an “Incident Report” for safetydocumentation and you should be cleared through the Emergency Department.Resignation/termination: Give us as much warning as possible when you need to leave yourvolunteer position so we can try to recruit new volunteers. We understand that life changes andyou may not be able to continue your commitment. We appreciate the help you have given nomatter how long you are able to stay with us. Volunteers are an important part of our customerservice plan and are expected to demonstrate commitment to the values of the Health System.Volunteers unwilling to meet these commitments and the commitment to improve performance maybe terminated from the volunteer program.Teens:Volunteering at a hospital is a serious responsibility and our program is designed for matureteenagers between the ages of 14 – 18. Because of the training and orientation process requiredwe should not be considered simply as a place to earn assigned Community Service hours. If youare planning a medical career or are interested in hospital volunteering on a regular basis(minimum 50 hours) consider applying for our summer student volunteer team. We accept a fewteenagers during the school years and increase the number in the summer months. Volunteers onhealth care career tracks should ask about our SCRUBS program (Students Can Really UseBedside Skills). The SCRUBS summer camp is for students 13, 14 and 15 and SCRUBS “U”evening sessions are held on career topics quarterly.Note: The minimum age to volunteer 14 years old. Limited positions are available for mature teenvolunteers primarily in the summer months. Teen volunteers are limited by Labor Law restrictions to lessthan 18 hours of service a week or 3 hours a day during school session, and 40 hours a week or 8 hours aday when school is not in session limiting service to between 7 a.m. – 7 p.m. Critical patient areas such asEmergency, Operating Room, ICU etc. have their own age guidelines for service.RSVP: The initials RSVP stand for the Retired & Senior Volunteer Program, an umbrellaorganization that welcomes retired volunteers over the age of 55. RSVP is sponsored locally bythe Carolina Lowcountry American Red Cross and is supported by the United Way.RSVP members may only work at their chosen facility or may offer to be involved in other areaevents. Members are mailed a regular newsletter and included in recognition special events.Roper St. Francis facilities have been successful stations for RSVP members for many years. Askyour coordinator for a membership card or for more information call RSVP offices at 744-8021extension 3079.9

Keeping our Hospital Safe - A Culture of SafetyNational Patient Safety GoalsPatient safety has become one of the most important challenges facing the American health caresystem and everyone at Roper St. Francis Healthcare is needed to promote the "culture of safety"that is our goal.At all times:• Consider your actions and how they may affect patient safety• Stay alert for things that don't seem right• Take appropriate steps to address a problemThe Joint Commission, which accredits hospitals, has published a list of patient safety goals that allhospitals must address. By wearing our nametag you are agreeing to join us as we do everythingwithin our power to help us protect our patients safety by meeting these goals. From BoardMembers and Physicians, clinical staff to volunteers as well as the patient and their loved ones, weeach play a key role in promoting a culture of safety. Review some of the Patient Safety goalsbelow and think of ways volunteer can help make the hospital a safer place.Improving the Accuracy of Patient Identification: Use at least two identifiers when providingcare such as helping to feed a patient or taking care of a newborn and mother.Improve the effectiveness of Communication among CaregiversVolunteers can help facilitate communication across the entire team. A volunteer can make a greatdifference in a patient's outcome by letting others know about issues we see.Improve the Safety of Using MedicationsVolunteers are not involved in taking any orders or giving any medications at RSFH.Reduce the risk of health care associated infectionsThis means the use of hand hygiene by everyone in the hospital - including volunteers.Encourage the patient’s involvement in his or her own careSome volunteers work directly with patients. All of us can help assure that our patients and familymembers have the information they need and help them get their questions answered.Preventing Falls: Be aware of the “STOP – Call Don’t Fall” symbols notingpatients on “fall precautions”. Leave items within a patient’s reach on bedsidetables. Encourage patients to call for help. Notify housekeeping promptly aboutspills. Stay safe yourself!_______________________________________________________________________________________________Important Safety InformationAs Volunteers we have a responsibility to be aware of our hospitals safetypolicies. Look around the area you work, find the exits, fire extinguishers andalarm pulls. Always be alert for safety hazards and report them. Rememberthe number to call in any emergency is 2911. Our Safety Office is DavidProvenzano. Our safety drills have code names:(* Note: At Roper Berkeley Day Hospital call 2911 for all emergencies.)10

Code: Red – FireIn case of a fire, call 2911 and pull a fire alarm pull to report a fire. Some of our fire alarms have aclear plastic cover that must be lifted to pull the handle. We have smoke detectors and sprinklersin every room, which are activated in the effected area.Alarms outside your area: If a Code Red is called outside your department, stay where you are.Close all doors. Stay calm and reassure patients and visitors. Do not yell “FIRE”. Remember notto use elevators during a fire drill.Remember the word “RACE” for Fire Safety facts:R Rescue anyone in immediate dangerA Activate the alarm by calling 2911 or pulling fire handle.C Contain the fire. Close all doorsE Extinguish if you can do so safely or Evacuate if directed byyour department evacuation plan.Remember the word “PASS” for Fire Extinguisher facts:P Pull the pinA Aim at base of fireS Squeeze the handleS Sweeping motion at the base of the fireUse only hospital approved extension cords. Don’t overload outlets. Watch for damaged andfrayed cords and report them. Be a walking safety monitor.Code: Dr. MaydayDr. Mayday is the code name used for a medical emergency. Call 2911, say “Dr. Mayday” andgive the location of the emergency. Stay clear and be available to run errands. Check with theVolunteer Coordinator about dates for CPR classes to be prepared in an emergency.Code Yellow: Code Yellow means a person is Security is needed. Call 2911 and report thesituation. Do not restrain the person, but reassure patients and visitors until the situation is undercontrol.Code Triage: A code triage is called when there is a disaster such as an earthquake, hurricane orgas leak when we must be on alert for incoming patients. Let your area manager know you arethere to help. Find out where the Command Center is. Media and press with questions in adisaster should be referred to the Marketing Department or Administration. Note: During a CodeStrom or Hurricane we are most concerned with your safety and recommend that you follow anymandatory evacuation advisory.Code Adam: Code Adam is called when an infant or child has been abducted. Be alert and reportany suspicious characters. Cover all exits during a Code Adam and until staff members arrivenotify guest that we are in a code situation and ask them to wait. Look for anyone trying to exitwith an infant/child or large bags. Instruct them that there is a problem and the exit is closed andthey should wait with you for staff to arrive. Do not struggle with an uncooperative person but takenote of their description. If they leave against instruction follow them to see where they go and/orget a description, tag number of a car while yelling for help. A Code Adam is called by calling2911.11

Code Orange: Code orange is called for a bomb threat. If you receive a bomb threat call, keepthe caller on the phone. Be alert to the caller’s voice, sex, age, background noises and anythingthey will tell you about the bomb.Notify 2911.MSDS: MSDS stands for Material Safety Data Sheet and contains information about each solutionand chemical used in the hospital and how to use them safely. All containers must be clearlylabeled as to the contents, hazardous warnings and manufacturer. Never use anything without alabel on it. MSDS information is conveniently found on the system intranet and always available.Chemical spills should be reported to the department where the spill occurred.Infection Control:Studies have shown that over 100,000 people die every year from infections they acquire while inthe hospital. We are determined to make Roper St. Francis Healthcare facilities as clean and safeas possible.The number one thing we can do to prevent infection is the simplest – wash our hands. Everyonewho has patient contact MUST wash their hands before and after contact with a patient or theirenvironment. Don’t be afraid to remind others of this requirement. Keep your nails short andtrimmed. Wash your hands thoroughly and for 10 – 15 seconds.Wash your hands!♦ Before handling patient’s food and trays.♦ Before eating and after using the restroom.♦ Before and after caring for each patients.♦ After handling patient’s articles or equipment.♦ Before leaving any clinical area such as the lab or physical therapy.Volunteers should make every effort not to expose themselves to blood and body fluids. Whenworking with patients we need to all be aware of ways that disease is spread and how to protectour patients and ourselves. Volunteers should not enter the rooms of patients on IsolationPrecautions.(SCRUBS Mentoring students will get specific instructions regarding Isolation Precautions.)The expression “Standard Precautions” means treating all patients and body fluids as if theywere infectious. The term “PPE” stands for Personal Protective Equipment – the gloves andmasks used by healthcare workers to do their job safely. It is important to know how to protectyourself. A copy of the hospital’s Infection Control Plan is now online but always available. If youever see an exposed needle or sharp – report it to the first healthcare worker you see so it can bedisposed of properly.Handwashing is the most important way to prevent the spread of infection.Body mechanicsYour health and safety is very important to us! Avoid unnecessary injuries byusing proper body mechanics. The basic principals are:♦ When turning, pivot with your feet and avoid twisting your body.♦ Analyze the work to be done and ask for help with heavy work.♦ Distribute the weight to be carried evenly.♦ Maintain a wide base of support and use a secure grip.♦ Tighten your abdominal muscles, time and coordinate your lift.♦ Push rather than pull.12

The next step is up to you!Carefully consider what you have learned and decide if service to the patients of Roper St. FrancisHealthcare would be mutually beneficial. To proceed with registration in the Volunteer Departmentplease complete the following:What next?Application Form, Competency Quiz, Background Check Form, Standards of BehaviorTurn in Reference Letter. You can bring it in a sealed envelope or have it sent directly tothe Volunteer Office in the facility you plan to serve.Bring a permission note from your physician if you have severe physical limitations effectingplacement.Get your TB test done and return to have it read. Important: Teens need parents orguardians signature. Use the Health Office numbers in the handbook if you need to call andsay “I am a new volunteer and need to schedule my TB test”. Note days the offices are open.Volunteer service depends on a satisfactory return on your HirEase background check.All done? Call the volunteer coordinator to discuss your assignment, uniform and nametag andarrange your first service shift. Let your coordinator know of any problems or concerns. Don’t startwork before your file is complete!Welcome!13

Roper St. Francis Healthcare Volunteer Core Competency QuizName: _______________________________________Date: __________________Mission:1) What is the Mission of Roper St. Francis Healthcare?:_____________________________________________________________________________General Policies & Dress Code2). It is important to be identified as volunteers and record your hours at all times while on duty.True False3). Volunteers are expected to be polite, pleasant and cooperative even in times of stress.True FalseHealth Services4). If you are injured on the job you should:a). Report the incident to your supervisor or the volunteer coordinator.b). Seek medical attention in the Employee Health Office or Emergency Department.c). a & b5). TB test or screenings should be done annually while you are an active volunteer.Yes NoConfidentiality & HIPAA6). Should a volunteer give out any information concerning a patient’s medical condition?Yes No7). Should you tell your neighbor’s wife that her husband has just been brought to the Hospital?a). Yes. You would want to know in the same situation.b). No. Tell the nursing staff that you know the patient’s wife and offer to help if they needto find her.8). Should you stop by your close friend’s husband’s room?a). Yes. You have known him for years and he would love to see you.b). No. If you only learned of his stay by looking at a hospital report you shouldn’t go intothe room unless your job takes you there.9). What should you do with patient information you are finished with?a). Throw it in the trash.b). Make sure it gets shredded.10). When are you allowed to repeat protected health information that you hear on the job?a). After you no longer work at the hospital.b). After the patient diesc). Only if you know the patient won’t mind.d). Only when it is necessary to do your job.Safety11). The main emergency number for the hospital is: ________________12). Can you use an elevator during a fire alarm? Yes NoMatch the following: a). Disaster ___ Code Adamb). Code Red___ PPEc). Infant Abduction___ Fired). Personal Protective Equipment ___ Code Yellowf). Person out of Control___ Code Triage (Blue)14

Infection Control14). What is the most important factor in preventing the spread of infection? __________15). Volunteers should avoid contact with blood and body fluids. Yes NoAge appropriate care16) In caring for elderly patients it is important to: (circle correct answers)a). Keep the environment safeb). Raise the side rails on the bedsc). Keep the bed in a low positiond). All of the above.Body Mechanics17). When lifting an object it is important: (circle correct answers)a). Ask for assistance with heavy workb). Push heavy objects rather than pull themc). Keep heavy objects close to your bodyd). All of the above.Topics covered in Orientation:(Check the box if you feel knowledgeable with the information presented in Orientation on this topic. Let yourCoordinator know if you need more information on any topic.) Mission & History Body Mechanics Phone Use Dress Code On the Job Injuries Infection Control Signing in and out Health, TB, Hep B Confidentiality/ HIPAA Wheelchair Operation The Right Thing to Do Fire and Electrical SafetyReceipt of Volunteer Handbook:I received the Orientation Handbook and have been given an opportunity to ask questions.YesNoHIPAA Video:I watched the video on HIPAA/ Confidentiality: Yes NoVolunteer Information• Pictures of volunteers in action and at events are often used in our newsletter and system publications.Volunteers of the Month photos are sent to area publications. May we include photographs in which youare included? Yes No• Periodically we publish a Volunteer Directory for use by other volunteers. This includes address,birthday (not year) and service areas. Would you like to be included? Yes NoConfidentially ReminderVolunteers have access to confidential information. You may be subject to inquiries from other volunteers orpersonnel from outside the hospital but you must not divulge confidential information to anyone unless suchinformation is normally communicated as part of your volunteer work assignment according to hospital policy.I understand that the release of confidential information to unauthorized individuals is grounds for dismissalfrom the Volunteer Program.Signature: __________________________________ Date: ______________________15

STANDARDS OF BEHAVIORSERVICEService Excellence is the cornerstone of healthcare. At RSFH, we strive to provide service withrespect, compassion, and integrity.I will:• Make eye contact, smile and project a “Can Do” attitude• Treat everyone with respect• Anticipate and be attentive to the needs of those we serve• Acknowledge others, Introduce myself, and say Thank-you• Show compassion towards others• Address service shortfalls with a sincere apology and activate the ‘Service Recovery’ planTEAMWORKWe are committed to a workplace that fosters healthy and supportive relationships. Throughteamwork, respecting coworkers and recognizing personal contributions, we will meet this goal.I will:• Be flexible and willing to help others• Work together with all departments to achieve success• Be loyal to coworkers and not participate in gossip• “Manage Up” by promoting and highlighting the strengths of others• Understand how my attitudes and actions affect everyone with whom I come in contactPROFESSIONALISMWe express respect and pride in serving our patients and community through our personalappearance and professionalism. Our manner and expression convey our commitment to providequality patient care.I will:• Confidently apply my skills and knowledge• Dress professionally and discreetly, adhering to the hospital and department dress codepolicies• Wear identification badge at all times clearly visible, above the waist, with photo facingoutward• Pursue professional growth and development• Remain respectful and sensitive in all situationsACCOUNTABILITYAccountability is taking ownership of one’s actions. We are dedicated to meeting and exceedingour professional responsibilities.I will:• Take ownership of my actions and decisions• Acknowledge mistakes and actively seek resolutions• Not make excuses or blame others• Be aware of my surroundings and report misconduct• Arrive on time and complete my assignments• Not be wasteful of time or resources16

SAFETYSafety is everyone’s responsibility. We are committed to creating and maintaining a clean, safeenvironment for our patients, their families, and our employees.I will:• Use equipment as intended and report any malfunctions• Know the meaning of and how to respond to all safety codes• Utilize security measures when appropriate• Pick up trash rather than walk by it• Understand and follow the National Patient Safety GoalsINNOVATIONInnovation is the process of creating and managing new ideas and methods to improve ourhealthcare system and services.I will:• Focus on creative solutions• Seek a better way to improve organizational performance• Challenge the status quo• Make ‘Excellence’ the goal in everything I doRIGHTSWe will provide a secure and trusting environment. We will treat all information as confidential,recognizing its impact on patient care.I will:• Respect the privacy of others and access only the information needed to treat patients• Not discuss personal information in public areas• Knock on the door before entering a patient’s room• Address conflict with others in private• Not impose my personal beliefs upon others• Treat others how I want to be treated (Golden Rule)COMMUNICATIONWe will demonstrate effective communication with our patients, families, and coworkers to ensure acommon understanding.I will:• Actively listen and ask when in doubt• Be mindful of my body language• Put a smile in my voice• Seek interpretive services when needed• Make sure what I have said is clear and understood• Meet face-to-face, call when I cannot meet, and use written communication (e-mail) only asa last resort• Ask if there is anything else I can doI understand that Roper St. Francis Heathcare is committed to a Journey to Excellence. I will makeevery effort to hold my behavior these high standards and understand that my position as aVolunteer is based upon these Standards of Behavior.Printed Name: ____________________ Signature: _________________Date: ____________17

ID Badge Authorization FormType: Staff Volunteer Clergy Allied Barton Security Healthcare Parking Temp (Contract Dates: )Reason: New Name Change Title Change Broken/Not Working LostStyle: Standard White ID Badge Pink ID Badge First Name OnlyFacility: Bon Secours St. Francis Roper Hospital Other:Legal Name:(First Name) (Middle Initial) (Last Name)Employee’s First Name (If other than Legal Name):Employee #Department Name:Corp # Department #:Employee’s Title: RN LPNChurch Name (Clergy Staff only): Give ID Badge to Employee Send ID Badge to Human Resources w/formSignature of HR/Manager Authorizing ID Badge(**HUMAN RESOURCES MUST SIGN FOR ALL RSFH STAFF NEW HIRES AND CHANGES**)DO NOT WRITE BELOW THIS LINENew ID Badge #Date:Note: Write the badge number of this form and fax the information to Human Resources and Healthcare Parking. Please verifybadge number for accuracy.

Roper St. Francis HealthcareAdult Volunteer ApplicationThank you for your interest in volunteer opportunities at Roper St. Francis Healthcare.Please complete the application and return it to the Volunteer Office.(Facility addresses on back)Name: _______________________ Day Phone: ____________ Date of Application: ____________Home Address: ______________________________________________________________________________________________________________(zipcode)Social Security Number: ______________________ Birthday: _____________(day and month)Are you currently employed? Yes NoIf yes, where? ______________________________ Work phone number: ________________Name, address and phone number of emergency contact:Name: ____________________________________ Phone: ___________________________Address: __________________________________ Relationship to you: _________________Do you have friends or relatives working for Roper St. Francis Healthcare? Yes NoIf “Yes” give their name, relationship and department: _________________________________Have you worked as a volunteer before? Yes NoIf yes, where? _________________________________________________________________Have you ever volunteered at a Roper St. Francis Healthcare facility before? Yes NoIf yes, which one? ______________________________________________________________Which service area, what year and reason for leaving? _________________________________Special skills or talents you have to offer as a volunteer (typing, computer skills, languages etc.)_____________________________________________________________________________Have you ever been convicted, plead guilty, plead no contender, or forfeited bond to a violation ofany federal, state, county or municipal law, regulation or ordinance other than motor trafficviolations? Yes NoIf “yes” please list the date and place of offence, the charges and disposition.(The existence of a criminal record does not constitute an automatic bar to volunteer placement):_____________________________________________________________________________Note: Adult volunteers require a SLED (SC Law Enforcement Division) check done for security purposes.

Are you a citizen of the U.S.A.? Yes NoIf the answer is “No” are you legally permitted to work in the USA? ________________________Why would you like to volunteer? ___________________________________________________Interests and time preferences:Is there anything we need to consider in placing you in a volunteer assignment?______________________________________________________________________________Check days preferred: Sunday Monday Tuesday Wednesday Thursday Friday SaturdayTime Preference:Interests: Morning Afternoon Evening Clerical Patient Contact Reception/Visitor ContactI understand that Roper St. Francis Healthcare reserves the rights to accept or reject my applicationin its sole discretion and that the above statements made in this application are true. I understand thatmy service will be in accordance with the general personnel policies and guidelines of Roper St.Francis Healthcare, Inc. I understand that I may quit at any time with or without cause and should theCoordinator of Volunteers feel that the interests of the hospital are best served by relieving me of myassignment or transferring me to another service, I agree to accept her decision as final.Believing that the hospital has a real need of my services as a volunteer worker who serves withoutpay, I will uphold the Mission and Values of Roper St. Francis Healthcare.Signature: ______________________________________ Date: __________________________Return application to the facility you are interested in:Roper Hospital 724-2828Volunteer Office, 316 Calhoun St., Charleston, SC 29401Bon Secours St. Francis Hospital 402-1156Volunteer Office, 2095 Henry Tecklenburg Dr., Charleston, SC 29414Roper Berkeley Day Hospital 899-7700(Send to Roper Hospital address above)Lowcountry Senior Center 762-9555865 Riverland Drive, Charleston, SC 29412Orientation: ______________ Start Date: _____________ Badge: ______________Service Area: ______________ Schedule: _____________ Sign in Sheet:_________TB Test: ______________ Card: _____________ Job Description:_______

Healthcare Mentoring Program ApplicationRoper St. Francis HealthcareThank you for your interest in the Health Career Mentoring programs opportunities offered at Roper St. FrancisHealthcare. Complete the application and return it to the Volunteer Office.(Facility addresses on back)Name: _______________________ Day Phone: ____________ Date of Application: ____________Home Address: _______________________________________________________________________________________________________________________________(zipcode)Social Security Number: ______________________ Birthday: _________________(day and month)Are you currently employed? Yes NoIf yes, where? __________________________________ Work phone number: ________________E-mail address____________________________________________________________________Name, address and phone number of emergency contact:Name: _________________________________________ Phone: ___________________________Address: _______________________________________ Relationship to you: _________________ SCRUBS Health Care Mentoring Program Rehab ShadowingHow did you hear about the Mentoring Program? _________________________________________What is your career interest at this time: ________________________________________________Where are you in your career pathway? (Educational level, school attending): __________________Where do you hope to continue your chosen career? (Schools, university): _____________________What year do you anticipate starting? ______________________ Graduating? _________________Comments: _______________________________________________________________________Note: How many hours do you anticipate serving? ____________Days & times you are most available:________________________________________________________________________________Do you have friends or relatives working for Roper St. Francis Healthcare? Yes NoIf “Yes” give their name, relationship and department: ______________________________________Have you worked as a volunteer before? Yes NoIf yes, where? _____________________________________________________________________

Special skills or talents you have to offer as a volunteer (typing, computer skills, languages etc.)________________________________________________________________________________Have you ever been convicted, plead guilty, plead no contender, or forfeited bond to a violation ofany federal, state, county or municipal law, regulation or ordinance other than motor trafficviolations? Yes NoHonesty is important. If “yes” please list the date and place of offence, the charges and disposition.(The existence of a criminal record does not constitute an automatic bar to volunteer placement):_____________________________________________________________________________Note: Adult volunteers require a Hirease (National Background) check done for security purposes.Are you a citizen of the U.S.A.? Yes NoIf the answer is “No” are you legally permitted to work in the USA? ___________________________Availability: Interests and time preferences: ____________________________________________Is there anything we need to consider in placing you in a volunteer assignment?________________________________________________________________________________I understand that Roper St. Francis Healthcare reserves the rights to accept or reject my applicationin its sole discretion and that the above statements made in this application are true. I understand thatmy service will be in accordance with the general personnel policies and guidelines of Roper St.Francis Healthcare, Inc. I understand that I may quit at any time with or without cause and should theCoordinator of Volunteers feel that the interests of the hospital are best served by relieving me of myassignment or transferring me to another service, I agree to accept her decision as final.Believing that the hospital has a real need of my services as a volunteer worker who serves withoutpay, I will uphold the Standards of Behavior and Mission of Roper St. Francis Healthcare.Signature: ______________________________________ Date: __________________________Return application to the facility you are interested in:Roper Hospital 724-2828Volunteer Office, 316 Calhoun St., Charleston, SC 29401Bon Secours St. Francis Hospital 402-1156Volunteer Office, 2095 Henry Tecklenburg Dr., Charleston, SC 29414Roper Berkeley Day Hospital 899-7700(Send to Roper Hospital address above)

Roper St. Francis HealthcareJunior Volunteer Application (14 - 18 years)Thank you for your interest in volunteer opportunities at Roper St. Francis HealthcarePlease complete the application and return it to the Volunteer Office.(Facility addresses on back)Name: _____________________________ Date of application: ___________________Home Address: _______________________________________________________(zip)Phone: ____________________ Age: _________ Date of birth: ___________________School: ___________________ Grade: ________ Email: ________________________Club memberships and Community affiliations: __________________________________Name, address and phone number of person to be contacted in case of any emergency:Name: _________________________________ Phone: ________________________Address: _______________________________ Relationship to you: ______________Do you have friends or relatives currently working/volunteering for Roper St. FrancisHealthcare? Yes NoIf yes, give their name, relationship and department: ____________________________Have you worked as a volunteer before? Yes NoIf yes, where? ___________________________________________________________Special skills or talents you have to offer as a volunteer (computers, clerical skills,languages etc.): _________________________________________________________Service time preferences:Are there any limitations to be considered in selecting your volunteer assignment?______________________________________________________________________Check days preferred: Sunday Monday Tuesday Wednesday Thursday Friday SaturdayTime preference: Morning Afternoon EveningInterests: Clerical Patient Contact Reception/Visitor Contact _____________Why would you like to volunteer? (Mention hours needed for community service, requiredobservation hours etc.) ___________________________________________________Career goals (if known): ___________________________________________________

Are you interested in helping with special events? (Bridge Run, American Heart Walk,Health Fairs etc.?) Yes No If I can!Agreement for Junior Volunteers – Roper St. Francis Healthcare1. While on duty, I will wear the approved badge and uniform and keep it neat and tidy. I will wear myuniform only while on duty or on the way to and from the hospital.2. I will not smoke or chew gum while in uniform at the hospital. I will not make unnecessary personalphone calls on hospital phones.3. I will remain in my scheduled service area except while at meals, breaks or on approved errands. I willnot leave my scheduled service area or the hospital during my scheduled hours without first obtainingpermission from the Volunteer Coordinator.4. I will take my breaks and lunch in approved eating areas.5. I will not change my assigned work schedule (days, hours or assignment area) without permission.6. I will sign out and leave the hospital grounds when my scheduled service hours are complete. I will usetransportation approved by my parents.7. I will record my hours accurately.8. I will not make personal visits to patient’s rooms while in uniform. If my service takes me into patientrooms I will not sit or lie on patient’s beds. I will wash my hands on arrival, leaving and between patientcontact. I will clear all patients’ requests with a staff member before filling them.9. When I am unable to work my scheduled time I will notify the Volunteer Office as far in advance aspossible. I will not report to work when I am sick.10. I understand the hospital is a place of business and that as a volunteer; I am representing the hospital ineverything I do and say. I will uphold the high standards expected by the public and my supervisors andwill at all times conduct myself in a mature and courteous manner.11. I will notify the Volunteer Office when I am no longer able to be an active Junior Volunteer.I understand that Roper St. Francis Healthcare reserves the rights to accept or reject my application in itssole discretion and that the statements made in this application are true. Should the Coordinator ofVolunteers feel that the interests of the hospital are best served by relieving me of my assignment ortransferring me to another service, I agree to accept her decision as final.Believing that the hospital has a real need of my services as a volunteer worker who serves without pay, Iwill uphold the tradition and standards of the Roper St. Francis healthcare.Signature: ____________________________________ Date: __________________________Parent’s consent: My daughter/son has my permission to work as a Junior Volunteer at Roper St. FrancisHealthcare. I believe that he/she is physically fit and mature enough to fulfill the duties to which he/she willbe assigned.Parent or guardian: ____________________________ Date: __________________________Return application to the facility you are interested in:Roper Hospital 724-2828Volunteer Office,316 Calhoun, St., Charleston, SC 29401Bon Secours St. Francis Hospital 402-1156Volunteer Office, 2095 Henry Tecklenburg Dr. Charleston, SC 29414Roper Berkeley Day Hospital 899-7700Volunteer Coordinator, 730 Stony Landing Rd., Moncks Corner, 29461Orientation: _____________ Start Date: __________ Badge: _____________Service Area: ______________ Schedule: _____________ Sign in Sheet:_________TB Test: ______________ Card: _____________ Job Description: ______

NOTICE/AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF ACONSUMER AND/OR INVESTIGATIVE CONSUMER REPORTI authorize Roper St. Francis Healthcare to verify all information within the Volunteer Application. I further understand thatRoper St. Francis Healthcare has contracted with HirEase Corporation to procure certain consumer and/or investigativeconsumer reports, as necessary, for use with its verification process to include a criminal background check, i.e., any criminalrecord information which may be in the files of any Federal, State or Local criminal justice agency in any State. I understandthat the results of this verification process will be used to determine my volunteer eligibility.I consent to the release of consumer and/or investigative consumer reports, as defined above, in connection with my applicationto volunteer at Roper St. Francis Healthcare. I further understand that this consent will apply during the course of time that Ivolunteer at Roper St. Francis Healthcare and that such consent will remain in effect until revoked in a written document signedby me. In the event that I wish to refuse or revoke my consent at any time, I understand that I may do so. I further understandthat Roper St. Francis Healthcare is relying on the information contained in my Volunteer Application, this Notice/Authorizationand Release and information otherwise disclosed to Roper St. Francis Healthcare by me, as true and correct information, and mayuse such information when verifying information, obtaining consumer reports and/or investigative consumer reports.According to the Fair Credit Reporting Act, if any adverse decision is made with regard to my application to volunteer, basedentirely or in part on the information contained in a consumer report or investigative consumer report, I understand that I amentitled to receive a copy of this report upon written request, and a disclosure of the nature and scope of the report.The Identifying Information for Consumer Reporting Agency is considered Confidential Information and will only be providedto designated personnel.I agree to release Roper St. Francis Healthcare, Hirease Corporation, and their associates from any and all claims and/or damagesarising from retrieving and reporting information per this Agreement.I acknowledge that I have carefully read the above Notice/Authorization and Release and, by typing or signing myname below, signify that I understand and agree to the terms and conditions therein.Signature: ___________________________________________Date: ________________IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY(Please fill out all information below. Without this information, we will be unable to properly identify you in the event wefind adverse information during the course of our background investigation.)Applicant Name: (First Middle Last)Current Address: (street address)Other Name(s) Used: (like Maiden) City: State: Zip:Social Security Number: Former Address: (1)Sex: Race: City: State: Zip:Month, Day and Year of Birth: Former Address: (2)City: State: Zip:A photocopy or telephonic facsimile (Fax) of this Notice/Authorization and Release shall be as valid as the original.

Letter of ReferenceHave someone who knows you well (not a relative) write us a brief noterecommending that we welcome you into the Roper St. Francis HealthcareVolunteer Department. We are looking for people who are kind, honorable,honest and respectful of our patients. The signed recommendation letter shouldbe placed in a sealed envelope or mailed to the appropriate facility:• Bon Secours St. Francis Hospital, Volunteer Office, 2097 Henry Tecklenburg Dr., Charleston, SC29414• Roper Hospital, Volunteer Office, 316 Calhoun St., Charleston, SC 29401• Lowcountry Senior Center, 865 Riverland Dr., Charleston, SC 29412Name:Address:Phone:Date:________________________________________________________________________________________________________________________Dear Volunteer Coordinator,I recommend that ____________________________ (name) be accepted intothe Roper St. Francis Healthcare Volunteer Hospital because:(Write your comments in this blank space)Signature:______________________________

Employee Health DepartmentRoper Monday-Friday 7:30-4St. Francis Tuesday & Thursday 7:30-4Phone (843) 724-2131 Fax (843) 724-1325Immunization Review and PPD FormName SSN - -________Signature Date / /________Guardian Signature (For minors) Date / /________Work Phone Home Phone Cell Phone _____________________ Roper Hospital St. Francis Hospital Roper Berkeley Other:Immunization Review: Check All That ApplyIf you do not have documentation, a blood draw will be done to check for immunity.Vaccination will be discussed based on documentation, immunity test results and personal risk factors.Hepatitis B Vaccine (HBV) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Hepatitis B Vaccination. I have not had Hepatitis B Vaccination.Rubeola Vaccine (Red Measles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Rubeola Vaccination. I have not had Rubeola Vaccination.Rubella (German Measles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Rubella Vaccination. I have not had Rubella Vaccination.Varicella-Zoster (Chickenpox, Shingles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I can report a reliable history of chickenpox or shingles. I do not know if I have had Varicella Illness or Vaccination. I have not had Varicella Illness or VaccinationTuberculosis ScreeningTwo PPDs are required before starting as a volunteer. If you had a TB skin test within the last 12 months bring the documentation.An annual PPD is required for those who continue on as volunteers.If you have ever tested positive to a TB skin test bring the documentation and your most recent chest x-ray.TB Tests need to be read between 48–96 hours. If the test is not read by 96 hours it must be repeated.One TB skin test must be read in the Employee Health Office. Bring a copy of your completed results to the Volunteer Office.What was the result your last PPD skin test?Have you ever been exposed to anyone with TB?Do you have Leukemia, Lymphoma, or another cancer?Have you been told that you have a disease of the immune system?Have you experienced an unexplained weight loss?Do you feel fatigued most of the time?Have you had a recent fever?Do you have night sweats?Do you have a persistent cough (dry, wet or bloody)?POSITIVEYesYesYesYesYesYesYesYesEMPLOYEE HEALTH STAFF USE ONLYNegativeNoNoNoNoNoNoNoNoSanofi Pasteur Lot # ____________ Exp. Date ______/______/_______ Site: LFA ____ RFA ____PPD planted _____/_____/_____ Planted by: __________________________________PPD read _____/_____/_____ Read by: ____________________________________UnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureResult ____________ (mm) (A Positive result is >/= 10 mm, or > 5 mm in an immunosuppressed person)Sanofi Pasteur Lot # ____________ Exp. Date ______/______/_______ Site: LFA ____ RFA ____PPD planted _____/_____/_____ Planted by: __________________________________PPD read _____/_____/_____ Read by: ____________________________________[] Entered ________[] Entered ________[] Entered ________[] Entered ________Result ____________ (mm) (A Positive result is >/= 10 mm, or > 5 mm in an immunosuppressed person) Past positive. No PPD skin testing required. Staff signature:Date: ____/____/_____ CXR: + PPD CXR: + Symptoms CXR: Past Positive CCHD Referral HBV Completed HBV Declined HBV Needed - Recall HBV Contraindicated RUBELLA Completed RUBELLA Declined RUBELLA Needed - Recall RUBELLA Contraindicated RUBEOLA Completed RUBEOLA Declined RUBEOLA Needed - Recall RUBEOLA Contraindicated VAR Completed VAR Declined VAR Needed - Recall VAR ContraindicatedC:\Documents and Settings\jperry\Local Settings\Temporary Internet Files\OLKD20\Volunteer Immunization and PPD Form.doc1/25/2008EnterAllIMM

Employee Health DepartmentPhone (843) 724-2131 - Fax (843) 724-1325Volunteer Information RecordVolunteer Name: First MI LastHome Address: StreetCityState Zip Home Phone Work PhoneAgeGeneral InformationReason for this visitPPDBlood WorkImmunizationsOther _______________Date of Birth(mm/dd/yyyy)/ /Social Security NumberMedical InformationAre you currently under a physician's care for any medical problems? No Yes: Please specify ______________________________________________________________________Do you have allergies to drugs or to food? No Yes: Please specify ______________________________________________________________________Personal Medical Provider:Name ________________________________________________Phone Number ________________________Emergency Contact:Name ___________________________Relationship _______________Phone Number ________________________I hereby voluntarily request, authorize and consent to medical care, diagnostic procedures and medical treatments as deemedappropriate by and delivered by RSFHC medical providers, related to the health problem(s) for which I have sought the services ofRSFHC. I further consent to have all relevant results and records of these diagnostic procedures and treatment forwarded to RSFHC. Ifurther authorize RSFHC to obtain my medical records, x-ray reports, physical therapy reports, laboratory reports, or other healthrelated information deemed necessary to allow the RSFHC medical provider to appropriately diagnose and/or treat my medicalcondition(s) and/or assess my ability to work. I further authorize RSFHC to release information contained in my RSFHC Medical recordnecessary for review for Workers Compensation directly to RSFHC and assign to them insurance benefits otherwise payable to me.I understand that I am financially responsible to RSFHC for charges not covered by the employer. In so doing, I hold harmlessRSFHC and its medical care providers from any liability regarding the release of information to RSFHC, the Insurance company for saidcompany, the cost containment company for said company or carrier, or any other party as required by law. A photocopy or facsimilecopy of this release is effective as an original document.Volunteer Signature___________________________________________________________Date ____/____/______C:\Documents and Settings\jperry\Local Settings\Temporary Internet Files\OLKD20\Volunteer Demograhics to Enter in Database.doc04/04/08