Volunteer Handbook - Roper St. Francis Healthcare

Roper St. Francis HealthcareVolunteer HandbookHealing all People with Compassion,Faith and Excellence.

Dear Volunteer,Welcome to Roper St. Francis Healthcare as you begin your new volunteer role. Uponacceptance to our volunteer team you become a member of a large “family” numbering over 475women, men and teenagers who serve 80 – 88,000 hours a year at Roper St. FrancisHealthcare. Volunteers have been an integral part of our staff for over 30 years withconsistently outstanding service enabling us to maintain the highest quality of care available.We are pleased that you have chosen to share your energy, time and talents with our patientsand employees. We believe your rewards will be great and that volunteering will add animportant dimension to your life.This online volunteer handbook has been made available to streamline your orientation process.Acceptance into the volunteer program depends on current positions available. Our needschange daily as volunteers come and go in the system. Contact the volunteer coordinator in thefacility that interests you before completing this process.Our office doors are always open or we can be reached by leaving a phone message or byemail. In an emergency you may call the Main Hospital Operator and ask them to page us.Please feel free to discuss any needs, concerns, ideas or interests. We hope your experiencehere will be a beneficial and rewarding one. We are glad you are here.Sincerely,Joan PerryLynne CollierDirector of VolunteersVolunteer CoordinatorBon Secours St. Francis HospitalRoper HospitalPhone: 843-402-1156 Phone: 843-724-2080joan.perry@RSFH.com Fax: 843-724-1987lynne.collier@RSFH.com1

The application process includes:Acceptance: Personal interview to match our needs with your interests.Orientation & Tour: Small group orientations are scheduled on a frequent basis and scheduled afteracceptance into the program. Review the handbook carefully before attending.Application & Paperwork: We are required to have a completed file on each volunteer. Yourvolunteer service depends on satisfactory reference letter, background and health screenings andcompletion of application paperwork.Health Screening: You will be instructed to report to a RSFH Employee Health Office for screeningbefore you begin to serve. Note the office hours at your facility. No appointment is required butplease follow the instructions:Bring the completed health forms from the back of your application packet.Bring any documentation of childhood immunizations that you have. These records would have beenrequired for school registration.Report to the nurse with your paperwork and say, “I am a new volunteer here for my health screening.”The nurse will review your immune status based on your records. If you have no records they will draw ablood sample. Volunteers under the age of 18 must provide their own records.The nurse will do a TB (PPD) skin test on your arm. The TB test needs to be examined within 48 – 96hours. If you do not come in to have it checked, it will not count.If you have not had a TB test within the last year you will be required to have two. You will be instructed toreturn for the second test. If you are on a healthcare career track you should ask for a copy for your recordsat this time.Applicants with a history of past positive PPD tests may be referred for a documenting X-Ray.Note: Obtain permission from your physician for serious conditions effecting placement.After absences for serious illness or surgery you should clear your return to service with your medicaldoctor.Employee Health Office HoursRoper Hospital: Weekdays: 7:30 – 3:30 p.m.Bon Secours St. Francis Hospital: Monday & Thursday; 7:30 – 3:30 p.m.Mount Pleasant Hospital: Monday & Thursday; 7:30 – 3:30 p.m.Letter of Recommendation: Ask someone who knows you well (not a family member) to write a briefcharacter reference letter recommending that we accept you into the program. Bring the letter in a sealedenvelope or have it mailed directly to the volunteer coordinator.Background Check: A HirEase Background Check will be performed at the hospital’s expense. Honestyis important as you complete your application.Starting Service: Complete your paperwork and health screening and schedule your first shift. A “skillschecklist” should be completed and returned to your file anytime you begin a new work area to makesure training in documented. Notify your coordinator before any unassigned change in service area orschedule.Completion of hours/resignation/termination: Give as much notice as possible if need to leave yourvolunteer position so we can recruit new volunteers. We understand that life changes and you may notbe able to continue your commitment. We appreciate your help no matter how long you stay with us.Volunteers are an important part of our customer service plan and are expected to demonstratecommitment to the values of the Health System. Volunteers unwilling to meet these commitments andthe commitment to improve performance may be terminated from the volunteer program.Students are with us for a specified number of hours. Let us know when you have completed your timewith us and turn in your ID badge.3

Dress CodeProfessional & Identified: It is important that you are clean, neat and identified as a volunteerwhile on duty. Shorts, jeans, spandex tights, sweatpants or mini skirts are not appropriate attire.Avoid chewing gum, eating or using a personal cell phone in customer service areas.Nametags: Nametags are provided and for security reasons must be returned if/when you leave.Uniform Options: Uniforms depend on the area you serve. Options include traditional salmonsmocks, cobbler aprons and polo shirts with solid color slacks.Shoes: Footwear should be comfortable, safe, and quiet and clean with tied laces. Avoid opentoes in clinical areas.Scents: Avoid perfume or scented after-shave products on your days of service as patients maybe sensitive to strong odors.Jewelry: Protect yourself and our patients by avoiding large dangling pieces of jewelry.Hair: Hair should be groomed. Long hair should be tied away from the face in clinical areas.Sign in: You are responsible for logging your arrival and departure in the Volunteer Sign office. Recordhours each time you serve, rounding numbers to the next 15 minutes. If you have completed yourservice hours please note completion on your last shift and return your badge.Personal belongings: The hospital cannot be responsible for personal property – do not bring valuablesto work with you or leave belongings unsecured in work areas.On The Job Injury: Stay safe! Notify your area supervisor and volunteer coordinator should any injuryoccur during your working hours. We will complete an “Incident Report” for documentation and youshould be cleared through the Emergency Department. Don’t Pass Out! Students finding themselveslightheaded after observing a medical procedure should make their employee mentor aware, sit down,lower their head and take deep slow breaths.Meals: A meal is provided to volunteers working a full volunteer shift of 3 - 4 hours. The purpose is totake care of us while we are on duty and we need to take care not to abuse this benefit. As foodexpenses rise there are facility specific guidelines that will be discussed at your orientation.Wear your uniform and ID 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 make frequentreturn trips for items.Keep a mental goal of spending around $6 or as directed by the coordinator in your facility. Onoccasion you may go slightly higher or lower.Breakfast is such a good deal that some volunteers pay for breakfast and then enjoy a free lunch.Remember to thank the food service employees!Parking: Free parking is available to volunteers but our goal is to leave the most convenient parking forour patients. Current options will be discussed during your facility tour.Employee events: Volunteers are welcome at employee events and forums throughout the year. TheVolunteer Department hosts an annual spring Volunteer Awards luncheon for active volunteers. You areencouraged to attend the quarterly “Employee Forums”.Health Benefits: Annual TB tests are required and provided. It is your responsibility to report to theEmployee Health Office annually. Free flu shots are available to active volunteers during flu season.Absences: Report to work on time for your scheduled shift. Another volunteer may be waiting for relief.If you know in advance that you will be absent let the staff in your work area and your volunteercoordinator knows. When possible arrange to exchange shifts with another volunteer trained in yourarea. For unexpected absences call the Volunteer Office and/or your work area. Never feel guilty aboutabsences due to illness. Your health is most important to us. You are protecting our patients and staffby not reporting to work with any infectious condition or fever.4

Inactive Status: Life changes. Let us know if you are unable to continue as planned or becomedissatisfied for any reason with your assignment. Volunteers inactive without notice or explanation forone month will be taken off the active roster and considered inactive in order to keep our recordsaccurate.Gifts & gratuities: Volunteers may not accept gifts of cash from patients.Difficult situations and abrasive callersDifficult situations frequently arise in healthcare where patients and their families are under a lot ofstress. We cannot solve everyone’s problems 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 isupset about and ask your supervisor for the correct method of referral. Remember they are not upsetwith you! You just 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: 402-1194Mount Pleasant Hospital: 606-7693The Right Thing to DoRoper St. Francis Healthcare has a reputation of high ethical standards and good citizenship. Ourreputation 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 and ethicalbehavior. We believe that the best way to fulfill our mission is for all employees and volunteers to behonest, ethical, and fair in business practices and personal behavior. This commitment includescomplying with all applicable laws and regulations in all areas including:Patient Care and ConfidentialityEqual Employment and Workplace Behavior.Conflict of InterestFinance and BillingAdmissions & referralsMedia Inquiries and AdvertisingSafeguarding Property & Technology SafetyRelations with Government Officials & Regulatory AgenciesIn cases where you need additional guidance on an ethics related issue or you simply feel somethingisn’t being done “right or fairly”, you should seek the advice of your supervisor or your volunteercoordinator. If you need additional help you may contact the Human Resources, Legal Services or theCorporate Compliance Office. If you are uncomfortable dealing directly with these offices you may callthe Compliance Help Line at 1–800-597-3386.Sensitivity ReminderAs members of the Roper St. Francis Healthcare VolunteerDepartment we welcome and care for all of our patients and visitorswithout regard to age, race, sex, color, religion or national origin.It is just as important that we use this same graciousness andsensitivity in the way we treat our coworkers and fellow volunteers.We hear the word “diversity” a lot lately. What does it mean to us ashealthcare volunteers? Most definitions describe the differencesbetween groups or individuals. Differences may include gender,educational, political and ethnical differences. People are not alikeand we must acknowledge that.5

Life would be boring if we were all the same. Diversity can range from slight differences, such as thosewithin family members, to major differences such as those between nations, religions, and geographicallocations. All of these diversities affect healthcare practices and beliefs.We believe in creating a healing environment and workplace that respects and includes differences,recognizes the unique contributions that individuals have to offer and makes the most of the potential ofall employees and volunteers as well as making our patients feel welcome and comfortable.We are fortunate to have volunteers both men and women, from 15 – 95, with fascinating culturalbackgrounds, students and former heads of companies. We have quiet folk who work in supportive rolesas well as the characters who keep us smiling. Diversity is part of the beauty of our group.Keeping this in mind, we should be mindful of what we say and how we act. Expressions that seemedacceptable when and where we grew up may not be now. Our behavior is a direct reflection of theVolunteer Services Department and our intent as volunteers is to support and add joy to the lives of ourpatients and co-workers. Times change and some of this can be confusing. If you have any questionsabout diversity please feel free to ask for more information. Our Human Resources staff is always willingto help us “do the right thing.”Confidentially & HIPAAThe privacy of our patients must be protected at all times. Medical records are by law, confidential andnot for public knowledge. Picture yourself as the fierce protector of our patient’s privacy.HIPAA stands for Health Insurance Portability and Accountability Act a part of the Social Security Actthat was signed into law in 1996 and enacted in 2003. HIPAA was put into place to improve healthcaresystems by standardizing electronic data exchange and to protect the security and privacy of information.The Privacy section of this law protects an individual’s personal health information and holds healthcareworkers and volunteers accountable for violations with heavy fines.Patients will be given information about their rights on admission. At this time they can even decide thatthey want to be completely private and in this case their name may be completely left out of our printedand computer directories. This means we couldn’t even tell their family members that they are here.We no longer use sign-in sheets where patients can see who has signed in earlier that day or directorieson walls listing patients progress.Important things to remember: Most confidentiality errors are made by good people trying to do the right thing. Since volunteers arevery 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 I need toknow that to do my job?” before accessing patient information. Protect all patient information from view by visitors, other volunteers and staff. Tilt computer screensaway from visitors. Don’t leave patient information lying out in the open. Do not used papers withpatient names on it to make scratch pads. Anything you learn about your patient is private and should not leave the hospital. We are ourpatient’s advocate and protector. 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 questions on this important topic pleasetalk to your volunteer coordinator.6

MediaIf the media (TV, radio, newspapers etc.) approaches you, refer them the Corporate CommunicationsOffice at 724-2834 or the Administrative Offices. Don’t even answer questions or make comments. Asvolunteers we can never know all sides of a story.NewsletterThe monthly “Volunteer’s Voice” has news and updates for all Roper St. FrancisHealthcare volunteers. Contact your coordinator with news or suggestions. Thingschange and departments relocate frequently. Our customers depend on us for currentinformation so please read the newsletter! Check employee and volunteer bulletinboards to stay current with activities.Our Journey to ExcellenceRoper St. Francis Healthcare facilities are part of a long tradition in the Lowcountry. We have been votedthe “Best Place to Work” and consistently rank high in patient satisfaction surveys. Our Journey toExcellence represents our renewed commitment to serve and operational excellence. This is an ongoingprocess dedicated to developing new and innovative ways to provide the very best patient care. We hopeyou see evidence of the positive changes that have taken place.RSFH Mission Statement:“Healing all People with compassion, faith and excellence.”Standards of Behavior: Join us on our Journey to Excellence by reading the Standards of Behavior inyour application packet and signing them. Some of the ways volunteers can make a difference are:Make eye contact and greet people with an approachable smile.Acknowledge others, introduce yourself and say “Thank-you.”Offer to help people get to their destination.“Manage Up” by promoting and highlighting the strengths of others.Wear identification badge at all times clearly visible, above the waist, with photo out.Pick up trash rather than walk by it.Knock on the door before entering a patient’s room.Address conflict with others in private.Be alert for people in need and learn how to refer them for help.Ask if there is anything else you can do.You will hear the staff using the following steps in dealing with patients and customers. It can be modifiedfor most volunteer roles.A: Acknowledge the patient.I: Introduce yourselfD: Duration – how long the procedure or wait will last.E: Explain what you are doing.T: Thank them for choosing RSFH.Commonly used hospital abbreviations or symbols:NPO: Nothing by MouthSTOP Call Don’t Fall: Fall PrecautionsTeardrop: A blue teardrop on a door symbolizes a stillborn or miscarriage.7

Population Specific CarePart of the pleasure of volunteer work in a hospital is that it brings us into contact with people of all ages.Here are some tips for relating to people of different age groups in a safe and appropriate way.Neonates (birth to 28 days): Neonates are dependent on others for all their needs. It is importantto encourage the parents to participate in the baby’s care as much as possible. Never leave ababy unattended.Children: Safety is important when caring for children. Keep the side rails up and make suretoys do not have removable pieces that could cause choking. Reduce overwhelming stimulationand always speak to a child before you touch them. Encourage parents to be involved in care.Use play to help with explanations. Favorite toys may provide security and comfort. With olderchildren demonstrate and explain everything before you do it and allow them to participate asmuch 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 so callers to the hospital will know that theitem has been turned in. If a caller has a question about an item, transfer them to the appropriatenumber. If a purse or wallet is turned into you do not open it since it may have been robbed already.Roper Hospital: Patient Representative Offices at 724-2045Mount Pleasant: Patient Representatives Office at 606-7693Bon Secours St. Francis Hospital: Support Services (back hallway) at 402-1176Telephone UseOur voice on the phone represents Roper St. Francis Healthcare. It is important togreet callers with an alert and friendly voice tending to their needs quickly andefficiently. Keep in mind that our callers are often contacting us under stressfulsituations when a family member is ill. We play a very important role calling for tactand courtesy.General tips: Be friendly and accurate. Answer promptly with a smile in your voice. Take messages accurately Identify yourself and location. Example: “3 rd Floor Nurses Station, Barbara, Volunteer, may I helpyou?” Outside Line: Dial “9” to get an outside line. Operator: Dial “0” Emergencies: 2911 You add a “2” to make four digits to transfer to a patient’s room. For example, transfer toextension 2118 for Room 118. HealthLine: For information about our physicians, medical questions or information about theHospital transfer the caller to the HealthLine at 402-2273.Roper Hospital: Patients dial “5” to get an outside line from their rooms. The prefix is: 724Bon Secours St. Francis Hospital: Patients dial 9 to get an outside line. The prefix is 402.Mount Pleasant Hospital: Patients dial 9 to get an outside line. The prefix is 606.8

Wheelchair transportation:Volunteers may transport and discharge wheelchair patients who do not require special assistancekeeping these rules in mind:Wash your hands and identify the patient. Check to see if the patient’s chart isto accompany the patient.The Nursing staff should completely discharge a patient making sure they haveall their instructions and prescriptions. If the patient needs assistance thenursing staff should help the patient to the wheelchair. The bed should be in alow position with the 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, pull handlesapart.Cover patients in gowns with a blanket or sheet making sure it does not dragon the ground. Cover the seat of the wheelchair before a patient in a gown sitsdown. Empty pillowcases are perfect for this.Before you let your patient be seated - push the footrests back, set the brake and grip the handles firmly.Position the patient’s feet in the footrests and advise him/her to sit back before releasing the brake.Stay to the right in corridors using caution at intersections. Use overhead mirrors to check for traffic. Backinto 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 on the handles.Don’t push a stretcher or patients with IV’s without an employee unless you have received special training.Student/Teenage Volunteers:Volunteering at a hospital is a serious responsibility and our program is designed for maturestudents over the age of 15. Because of the training and orientation process required we shouldnot be considered simply as a place to earn assigned Community Service hours. We can accepta few teenagers during the school years and increase the number in the summer months.Student volunteers are limited by Labor Law restrictions to less than 18 hours of service during aweek or 3 hours a day during school session, and 40 hours a week or 8 hours a day when schoolis not in session limiting service to 7 am – 7 pm. Critical patient areas such as Emergency,Operating Room, ICU etc. have their own age guidelines for service.SCRUBS Program:Students on health care career tracks should ask about our SCRUBS program (Students Can Really UseBedside Skills).SCRUBS Camp: The SCRUBS Camp is held in the summer for students between the ages of 13 – 15 whoare interested in exploring health careers. Applications are available by calling 402-2273 after thebeginning of each year.SCRUBS “U”: Evening career exploration sessions are held quarterly. Join the “SCRUBS Mentoring” fanpage on Facebook or ask to be added to the email mailing list.SCRUBS Mentoring Program: One-on-one mentoring program for students over the age of 16 iscoordinated by the Dream Pool coordinators. You can earn a certificate of completion after 40 hours in theSCRUBS program.9

Senior Volunteers:Advantage Membership: “Advantage” is an RSFH membership program for seniors 50 and older withmany benefits. The membership fee is waived for RSFH Volunteers. Call 724-2489 to register.RSVP: The initials RSVP stand for the Retired & Senior Volunteer Program, an umbrella organizationthat welcomes retired volunteers over the age of 55. RSVP is sponsored locally by the CarolinaLowcountry American Red Cross and is supported by the United Way. RSVP members may only workat their chosen facility or may offer to be involved in other area events. Members are mailed a regularnewsletter and included in recognition special events. RSFH facilities have been successful stations forRSVP members for many years. Ask your coordinator for a membership form or for more informationcall RSVP offices at 764-2323 ext. 379.Keeping our Hospital Safe - A Culture of SafetyNational Patient Safety GoalsPatient safety is one of the most important challenges facing the American health care system andeveryone 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 everything withinour power to help us protect our patient’s safety by meeting these goals. From board members andphysicians, clinical staff to volunteers as well as the patient and their loved ones, we each play a key rolein promoting a culture of safety. Review some of the Patient Safety goals below and think of waysvolunteers 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 agreat difference 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 noting patients on “fallprecautions”. Leave items within a patient’s reach on bedside tables. Encourage patients to callfor help. Notify housekeeping promptly about spills. Stay safe yourself!10

Important Safety InformationAs Volunteers we have a responsibility to be aware of our hospitals safety policies. Look around thearea you work, find the exits, fire extinguishers and alarm pulls. Always be alert for safety hazards andreport them. Remember the number to call in any emergency is 2911. Our Safety Officer is DavidProvenzano. Our safety drills have code names:(* Note: At Roper Berkeley Day Hospital call 5503 for all emergencies.)Code: Red – FireIn case of a fire, call 2911 and pull a fire alarm pull to report a fire. Our firealarms have a clear plastic cover that must be lifted to pull the handle. Wehave smoke detectors and sprinklers in every room, which are activated in theeffected area.If a Code Red is called outside your department, stay where you are. Close all doors. Stay calm andreassure patients and visitors. Do not yell “FIRE”. Remember not to 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 by your department evacuationplan.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 and frayedcords and report them.Code: Dr. MaydayDr. Mayday is the code name used for a medical emergency. Call 2911, say “Dr. Mayday” and give thelocation of the emergency. Stay clear and be available to run errands.Code Yellow: Code Yellow means a person is “out of control”. Call 2911 and report the situation. Donot restrain the person, but reassure patients and visitors until the situation is under control.Code Triage: A code triage is called when there is a disaster such as an earthquake, hurricane or gasleak when we must be on alert for incoming patients. Let your area manager know you are there to help.Find out where the Command Center is. Media and press with questions in a disaster should be referredto the Marketing Department or Administration.Code Adam: Code Adam is called when an infant or child has been abducted. Be alert andreport any suspicious characters. Direct visitors to use the main exit during a Code Adamdrill. Cover all exits during a Code Adam until staff members arrive. Look for anyone tryingto exit with an infant/child or large bags. Instruct them that there is a problem and the exit isclosed and they should wait with you for staff to arrive. Do not struggle with an uncooperativeperson but take note of their description. If they leave against instruction follow them to seewhere they go and/or get a description, tag number of a car while yelling for help. ACode Adam is called by calling 2911.11

Code Orange: Code orange is called for a bomb threat. If you receive a bomb threat call, try to keep thecaller on the phone and be alert to the caller’s voice, sex, age, background noises and anything they willtell you about the bomb. Notify 2911.MSDS: MSDS stands for Material Safety Data Sheet. The MSDS sheet contains information about eachsolution and 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 a labelon it. MSDS information is conveniently found on the system intranet. Call 2911 to report any chemicalspill.Infection Control:Studies have shown that over 100,000 people die every year from infections they acquire while in thehospital. We are determined to make RSFH facilities as clean and save as possible.The number one thing we can do to prevent infection is the simplest – wash our hands. Everyone whohas patients contact MUST wash their hands or use hand disinfectant before and after contact with apatient or their environment. Don’t be afraid to remind others of this requirement. Keep your nails shortand trimmed. Wash your hands thoroughly and for 10 – 15 seconds.Practice Hand Hygiene! Before handling patient’s food and trays. Before eating and after using the restroom. Before and after caring for each patient. 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. When workingwith patients we need to all be aware of ways that disease is spread and how to protect our patients andourselves.Volunteers should not enter rooms of patients on Isolation Precautions. (SCRUBS Mentoring studentswill get specific instructions regarding Isolation Precautions.)The expression “Standard Precautions” means treating all patients and body fluids as if they wereinfectious. The term “PPE” stands for Personal Protective Equipment – the gloves and masks used byhealthcare workers to do their job safely. It is important to know how to protect yourself. A copy of thehospital’s Infection Control Plan is now online but always available. If you ever see an exposed needleor sharp instrument – report it to the first healthcare worker you see so it can be disposed of properly.Body mechanicsYour health and safety is very important to us! Avoid unnecessary injuries by using proper bodymechanics. The basic principals are: When turning, pivot with your feet and avoid twisting your body. Analyze the work to be done. 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. For more information on any topic or to read the applicablepolicy please contact your Volunteer Coordinator. To proceed with registration in the VolunteerDepartment please complete the following:Application form and Orientation Core Competency QuizHave some one who knows you well (not a relative) write the brief letter of recommendation for us.You can bring it in a sealed envelope or have it sent directly to the Volunteer Coordinator in thefacility in which you plan to serve. Bon Secours St. Francis Hospital, Volunteer Office, 2097 Henry Tecklenburg Dr., Charleston, SC 29414 Roper Hospital, Volunteer Office, 316 Calhoun St., Charleston, SC 29401 Mount Pleasant Hospital, Volunteer Office, 6500 Hwy 17 North, Mt. Pleasant, S.C. 29466Bring a permission note from your physician if you have any severe physical limitations.Visit the Employee Health Office as instructed. Note days the offices are open. Minors need aguardian’s signature.Let your coordinator know of any problems or concerns.Welcome!13

RSFH STANDARDS OF BEHAVIORSERVICEService Excellence is the cornerstone of healthcare. At RSFH, we strive to provide service with respect,compassion, and integrity.I will:Make eye contact, smile and project a “Can Do” attitudeTreat everyone with respectAnticipate and be attentive to the needs of those we serveAcknowledge others, Introduce myself, and say Thank-youShow compassion towards othersAddress service shortfalls with a sincere apology and activate the ‘Service Recovery’ planTEAMWORKWe are committed to a workplace that fosters healthy and supportive relationships. Through teamwork,respecting coworkers and recognizing personal contributions, we will meet this goal.I will:Be flexible and willing to help othersWork together with all departments to achieve successBe loyal to coworkers and not participate in gossip“Manage Up” by promoting and highlighting the strengths of othersUnderstand 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 personal appearanceand professionalism. Our manner and expression convey our commitment to provide quality patientcare.I will:Confidently apply my skills and knowledgeDress professionally and discreetly, adhering to the hospital and department dress code policiesWear identification badge at all times clearly visible, above the waist, with photo facing outwardPursue professional growth and developmentRemain respectful and sensitive in all situationsACCOUNTABILITYAccountability is taking ownership of one’s actions. We are dedicated to meeting and exceeding ourprofessional responsibilities.I will:Take ownership of my actions and decisionsAcknowledge mistakes and actively seek resolutionsNot make excuses or blame othersBe aware of my surroundings and report misconductArrive on time and complete my assignmentsNot be wasteful of time or resources15

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 malfunctionsKnow the meaning of and how to respond to all safety codesUtilize security measures when appropriatePick up trash rather than walk by itUnderstand and follow the National Patient Safety GoalsINNOVATIONInnovation is the process of creating and managing new ideas and methods to improve our healthcaresystem and services.I will:Focus on creative solutionsSeek a better way to improve organizational performanceChallenge the status quoMake ‘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 patientsNot discuss personal information in public areasKnock on the door before entering a patient’s roomAddress conflict with others in privateNot impose my personal beliefs upon othersTreat 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 doubtBe mindful of my body languagePut a smile in my voiceSeek interpretive services when neededMake sure what I have said is clear and understoodMeet face-to-face, call when I cannot meet, and use written communication (e-mail) only as a lastresortAsk if there is anything else I can doYou will be asked to verify that you understand that Roper St. Francis Healthcare is on a Journey to Excellence,which requires a commitment to the Standards of Behavior.16

Volunteer Program ApplicationRoper St. Francis HealthcareThank you for your interest in the programs sponsored by theRoper St. Francis Healthcare Volunteer Department.Name: ____________________________________________________ Day Phone: ____________Home Address: _______________________________________________________________________________________________________________________________(zipcode)E-mail address_________________________________________________________ (print clearly)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? _____________________________________________________________________Days & times you are most available:_______________________________________________________________________________Special skills or talents you have to offer as a volunteer (typing, computer skills, languages etc.)________________________________________________________________________________Availability: Interests and time preferences: ____________________________________________Is there anything we need to consider in placing you in a volunteer assignment? ________________Have you ever been convicted, plead guilty, plead no contender, or forfeited bond to a violation of anyfederal, 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? ___________________________

Students applying for Shadowing or Mentoring Programs fill in this section: SCRUBS Mentoring PT/OT Shadowing Coding Externship MHAHow did you hear about the Mentoring Program? _________________________________________All students fill in this section:What school do you attend?: _______________________ Educational level: __________________What is your career interest at this time: ________________________________________________Where do you hope to continue your chosen career? (Schools, university): _________________What year do you anticipate starting? ______________________ Graduating? _____________Comments: _______________________________________________________________________How many hours do you anticipate observing/serving? ____________Minors: Students 15 – 18 should fill in this section:Why would you like to volunteer? (Mention hours needed for community service, required observationhours, etc.): _____________________________________________________________________Parent’s Consent: My daughter/son has my permission to work as a student volunteer at Roper St. Francis Healthcare.I believe that he/she is physically able and mature enough to fulfill the duties to which he/she has been assigned andabide by the schedule, safety, infection control policies and privacy standards as outlined in the Orientation Handbook.Documentation of service hours and transportation is the student’s responsibility. I understand that my signature isrequired for the necessary TB health screening and will provide documentation of childhood immunizations.Parent or Guardian Signature: _________________________________ Date: _________________________________________________________________________________I understand that Roper St. Francis Healthcare reserves the rights to accept or reject my application in its sole discretionand that the above statements made in this application are true. I understand that my service will be in accordance withthe general personnel policies and guidelines of Roper St. Francis Healthcare, Inc. I understand that I may quit at anytime with or without cause and should the Coordinator of Volunteers feel that the interests of the hospital are best servedby relieving me of my assignment 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 without pay, I will uphold theStandards 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 29414Mount Pleasant Hospital (send to St. Francis Hospital address above) 606-7000Revised 2/2009

Letter of ReferenceHave someone who knows you well (not a relative) write us a brief note recommending that wewelcome you into the Roper St. Francis Healthcare Volunteer Department. We are looking forpeople who are kind, honorable, honest and respectful of our patients. The signedrecommendation letter should be placed in a sealed envelope or mailed to the appropriatefacility: Bon Secours St. Francis Hospital, Volunteer Office, 2097 Henry Tecklenburg Dr., Charleston, SC 29414 Roper Hospital, Volunteer Office, 316 Calhoun St., Charleston, SC 29401 Lowcountry Senior Center, 865 Riverland Dr., Charleston, SC 29412 Mount Pleasant Hospital, Volunteer Office, 3500 N Highway 17, Mount Pleasant, SC 29466-9123Name:Address:Phone:Date:________________________________________________________________________________________________________________________Dear Volunteer Coordinator,I recommend that ____________________________ (name) be accepted into the Roper St.Francis Healthcare Volunteer Hospital because:(Write a note of reference above. Letter may also be written on your letterhead)Signature:______________________________17

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.TrueFalseHealth Services4). If you are injured on the job you should:a). Report the incident to your supervisor and the volunteer coordinator.b). Seek medical attention in the Emergency Department if indicated.c). a & b5). TB test or screenings should be done annually while you are an active volunteer.YesNoConfidentiality & HIPAA6). Should a volunteer give out any information concerning a patient’s medical condition?Yes7). 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 need to findher.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 into theroom 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 No20No

Match the following: a). Disaster ___ Code Adamb). Code Red___ PPEc). Infant Abduction___ Fired). Personal Protective Equipment ___ Code Yellowf). Person out of Control___ Code Triage (Blue)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 NoPopulation Specific 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.18.) I received and reviewed the Volunteer Orientation handbook and have been given an opportunityto ask questions.Yes No19.) I watched the video on HIPAA/Confidentiality: Yes No20.) Photographs: Pictures of volunteers in action and at events are often used in our newsletter,system publications and area publications. May we include photographs in which you are included?YesNo21.) Standards of Behavior: I understand that Roper St. Francis Healthcare is on a Journey toExcellence, which requires a commitment to the Standards of Behavior. I acknowledge I have received acopy of the Standards of Behavior and understand that my role as a volunteer requires that I embodythem.Yes NoConfidentially ReminderVolunteers have access to confidential information. You may be subject to inquiries from othervolunteers or personnel from outside the hospital but you must not divulge confidential information toanyone unless such information is normally communicated as part of your volunteer work assignmentaccording to hospital policy. I understand that the release of confidential information to unauthorizedindividuals is grounds for dismissal from the Volunteer Program.Signature: __________________________________ Date: ______________________21

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.TrueFalseHealth Services4). If you are injured on the job you should:a). Report the incident to your supervisor and the volunteer coordinator.b). Seek medical attention in the Emergency Department if indicated.c). a & b5). TB test or screenings should be done annually while you are an active volunteer.YesNoConfidentiality & HIPAA6). Should a volunteer give out any information concerning a patient’s medical condition?Yes7). 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 need to findher.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 into theroom 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 No19No

Match the following: a). Disaster ___ Code Adamb). Code Red___ PPEc). Infant Abduction___ Fired). Personal Protective Equipment ___ Code Yellowf). Person out of Control___ Code Triage (Blue)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 NoPopulation Specific 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.18.) I received and reviewed the Volunteer Orientation handbook and have been given an opportunity toask questions.Yes No19.) I watched the video on HIPAA/Confidentiality: Yes No20.) Photographs: Pictures of volunteers in action and at events are often used in our newsletter andsystem publications. Volunteers of the Month photos are sent to area publications. May we includephotographs in which you are included?Yes No21.) Directory: Periodically we publish a Volunteer Directory for use by other volunteers. This is optionaland includes address, birthday (not year) and service areas. Would you like to be included?YesNoConfidentially ReminderVolunteers have access to confidential information. You may be subject to inquiries from othervolunteers or personnel from outside the hospital but you must not divulge confidential information toanyone unless such information is normally communicated as part of your volunteer work assignmentaccording to hospital policy. I understand that the release of confidential information to unauthorizedindividuals is grounds for dismissal from the Volunteer Program.Signature: __________________________________ Date: ______________________20

Check boxes on right if you received information on each topic.Position Title: General Duty/Clerical Volunteer Revision Date: 1/11Department: Volunteer Facility: RSFH SystemReports To: Area Department Volunteer ContactCompetency Measurement Check BoxesMissionDress CodeOn the Job InjuryParkingSigning in/outHealth ScreeningFacility FamiliarityRestroom locationInformation DesksCafeteria/MealsReviewed.Follow up with EOH OfficeTourMet Met Met Met Met Met Met EquipmentTelephone useWheelchair SafetyReviewedReviewed in Orientation session.Verbalized understanding.Met Met HIPAAThe Right Thing to DoStandards of BehaviorReviewed and watched videoReviewed and/or watched video.Reviewed & SignedMet Met Met SafetyFire/SafetySafety CodesBody MechanicsUniversal PrecautionsInfection ControlEnd of service:Return of ID BadgeReviewed in OrientationQuiz on file.ReviewedOrientationMet Met Note: General Duty Volunteers do not offer direct patient care. General duty/Clerical volunteersoffer general support to staff and patients.Comments: Tour & HIPAA Video____________________ ________________________________ __________________Volunteer Volunteer Coordinator Date

Position DescriptionPosition Title: General Duty/Clerical Volunteer Revision Date: 1/2011Department: Volunteer Facility: RSFH SystemReports To: Department CoordinatorJob Summary: Assisting staff with clerical work and errands.Time Commitment: 3 – 4 hour shifts on a minimum of once a week schedule.Mature Junior Volunteers over the age of 14 may serve 2 – 4 hours as neededand scheduled.General Duties may include:Notify staff of your arrival and departure.Sign in and out in the Volunteer Office.Answer phones in a professional manner and relay messages accurately.Assist with filing, faxing and photocopying as requested and instructed.Give directions accurately. Escort when able.Data entry and typing if needed and instructed.Pick up and deliver mail to mailroom.Do not enter Patient Rooms under Isolation Precautions.Assist with non medical wheelchair transportation.Be familiar with department locations.Follow proper Hand Hygiene practices.Plan for absences.Knowledge/Skills:Must possess basic knowledge of all relative safety codes, i.e. OSHA, Infection Control, HIPAAregulations and know how to contact emergency help. Requires the ability to work well with alllevels of patients, the public and other health care professionals. Knowledge of floor plan andlocation of departments.Other:Neat appearance and the ability to maintain confidentiality.Contacts: Constant interaction with employees, physicians, patients and familymembers. General Duty Volunteers do not offer direct patient care.Work Demands/Environment: Occasional bending for files, walking and lightlifting. Requires the ability to see, hear and speak clearly.

Volunteer Record - 2011Name:Start Date: Previous Hours:Address: Zipcode Telephone:DOB: Email: TB Done TB 2010Emergency Contact: Phone: Teen Adult Rehab SCRUBSThis is your Personal Service Record. Sign in and out each time you serve.Date Service Area Time In Time Out Day Total Month Total**Write legibly! Round off-hours by 15 minutes. Please note your annual TB due date.Personal information is optional and may be used to send greeting cards etc.

Date Service Area Time In Time Out Day Total Month Total

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.

ID Badge Authorization FormType: Staff Volunteer Clergy Allied Barton Security Healthcare Parking Temp (Contract Dates): )Temp Contact Manager or Recruiter: Name _________________________ Phone ________________Reason: New Name Change Title Change Broken/Not Working LostStyle: Standard White ID Badge Pink ID Badge ER/BMU (Small Print Format)Facility: Bon Secours St. Francis Mt. Pleasant 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 Authorizing ID Badge (**HUMAN RESOURCES MUST SIGN FOR ALL CHANGES**)SECTION 1.01DO NOT WRITE BELOW THIS LINENEW ID BADGE #DATE:MT. PLEASANT ID # _________________________________NOTE: Write the badge number on this form and fax the completed form to Human Resources and Healthcare Parking.VERIFY BADGE NUMBER FOR ACCURACY

Employee Health DepartmentPhone (843) 724-2131 Fax (843) 724-1325Roper: Monday-Friday 7:30-3St. Francis & Mount Pleasant: Monday & Thursday 7:30-3Immunization Review and PPD Form 2011Name SSN - -________Signature Date / /________Guardian Signature (For minors) Date / /________Work Phone Home Phone Cell Phone _____________________ Mount Pleasant Roper Roper Berkeley St. Francis OtherImmunization Review: Please Check All That Apply If 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 Screening Two PPDs are required before starting as a volunteer. If you had a TB skin test within the last 12 months bring the documentation. 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. Bring a copy of your completed results to the Volunteer Office. An annual PPD is required for those who continue on as volunteers.What was the result your last PPD skin test?Have you ever been exposed to anyone with TB?POSITIVEYesDo you have Leukemia, Lymphoma, or another cancer? YesHave you been told that you have a disease of the immune system? YesHave you experienced an unexplained weight loss? YesDo you feel fatigued most of the time? YesHave you had a recent fever? YesDo you have night sweats? YesDo you have a persistent cough (dry, wet or bloody)? YesEMPLOYEE HEALTH STAFF USE ONLYNegativeNoNoNoNoNoNoNoNoUnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureSanofi Pasteur Lot # ____________ Exp. Date ______/______/_______ Site: LFA ____ RFA ____ [] Entered ________PPD planted _____/_____/_____ Planted by: __________________________________PPD read _____/_____/_____ Read by: ____________________________________[] Entered ________Result ____________ (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: ____________________________________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[] Entered ________[] Entered ________ VAR Needed - Recall VAR ContraindicatedEnterAllIMMS:\volunteer\Application Handouts\Application - PPD Health Form.doc 1/6/2011

Employee Health DepartmentPhone (843) 724-2131 - Fax (843) 724-1325Volunteer Information RecordVolunteer Name: First MI LastHome Address: StreetCityState Zip Home Phone Work PhoneAge Date of Birth Social Security NumberGeneral InformationReason for this visitPPDBlood WorkImmunizationsOther _______________Medical 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 harmless RSFHCand 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 ____/____/______S:\volunteer\Application Handouts\Application - EHO Form.doc