Kim Benz, Manager (231) 876-7149 Kbenz3@mhc.net

Application & Interview Process

Complete Application Packet Return to Volunteer Services in the envelope provided or mail to: Volunteer Services - Munson Healthcare Cadillac Hospital – 400 Hobart St. – Cadillac, MI. 49601 Application packet includes:

Application

Confidentiality Statement

Background Check Information Permission form

Statement of Understanding (2 copies – sign & return one copy)

Volunteer Application Questionnaire

Postage paid envelope Schedule Interview Complete & return Application Packet. Call (231) 876-7149 to schedule an interview. The Volunteer Services Office is located on the 4th floor of Munson Healthcare Cadillac Hospital.

Determination of placement is based on background check, available openings, ability and interest.

VOLUNTEER APPLICATION Please answer all questions. Type or print clearly.

CURRENT OR PREVIOUS EMPLOYMENT

Employer City/State

Phone Position

May we phone you at work regarding your volunteer activities? ⎕Yes ⎕No

Special Skills

⎕Language(s) ⎕Office/Clerical ⎕Computer ⎕Entertainment ⎕Other____________________________

over

NAME AND ADDRESS

Last Name First Name Middle Initial

Current Street Address

City State Zip

PHONE NUMBERS/E-MAIL ADDRESS

Phone: E-Mail Address:

EMERGENCY CONTACT INFORMATION

Name Relationship Phone Number

Address

CURRENT STATUS

⎕College or University Student

⎕Freshman ⎕Sophomore ⎕ Junior ⎕Senior ⎕Grad Student

⎕Community Resident ⎕Retired ⎕Other

REFERRAL SOURCE

⎕Radio/TV ⎕Friend ⎕Employer ⎕Church ⎕Newspaper ⎕Self Inquiry ⎕Other

PREVIOUS VOLUNTEER EXPERIENCE

Organization Role in Organization

Areas of Interest

⎕Emergency Dept. ⎕ Magazine Service

⎕Office/Clerical ⎕ Surgical Desk

⎕Spiritual Care ⎕ Tray Favors

⎕Gift Shop ⎕ Special Projects/Committees

⎕Escort Services ⎕ Baby Cuddler Program

REFERENCES – List 2 people outside your family (include complete mailing address)

Name Relationship Phone #

Mailing Address

Name Relationship Phone #

Mailing Address

Do you have any medical history or physical condition of which we should be aware that may limit your ability to do the

job? ⎕ No ⎕ Yes – brief explanation

Are you currently employed in the Munson Healthcare Cadillac Hospital? ⎕ No ⎕ Yes – where?

Have you ever been employed in the Munson Healthcare Hospital System? ⎕ No ⎕ Yes – in what capacity

Have you ever been convicted of a crime(s) including misdemeanors other than minor traffic offense? ⎕ No ⎕ Yes

If yes, please give details and current status.

Are there any felony charges outstanding? ⎕ No ⎕Yes – if yes, please give date, place, charge and current status.

Are you volunteering to satisfy a court required community service? ⎕No ⎕Yes – please list your probation officer’s

name and phone number.

Munson Healthcare requires all employees and volunteers to receive a 2-Step TB test and flu vaccine during the flu season in the year that they are hired and annually thereafter. Will you be able to comply with the Seasonal Flu Vaccine? ⎕ Yes ⎕ No Munson is a smoke free environment. To help promote a healing and safe environment, volunteers and staff may not smell of smoke at any time during the workday. In addition, smoking is not permitted on any Munson Healthcare Cadillac Hospital property, including in any vehicle on Munson Healthcare Cadillac Hospital property. Will you be able to comply with the No Smoking policy? ⎕ Yes ⎕ No

I certify that the responses on this document are true to the best of my knowledge. I agree that this information may be verified and

references contacted by Munson Healthcare Cadillac Hospital Volunteer Services. Misrepresentation of facts constitutes cause for

denial of application and/or dismissal from volunteering at Munson Healthcare Cadillac Volunteer Services.

Signature_____________________________________________________________Date___________________________

Kim Benz, Manager (231) 876-7149

kbenz3@mhc.net

Volunteer Application Questionnaire

What interests you about volunteering for Munson Healthcare Cadillac Hospital?

Why did you choose Munson Healthcare Cadillac Hospital to volunteer?

Please describe your interests, hobbies and any special skills you would be willing to share.

What is your availability (hours, days, etc) for your volunteer commitment?

Do you go away for the winter and/or summer months for more than one month or more?

Do you have any health issues or physical limitations that might prevent you from performing

certain types of volunteer work?

Do you have your own transportation to and from the hospital?

DATE:

Volunteer Candidate Name:

Form #195 (02/15)

Confidentiality Agreement

It is the policy of Munson Healthcare and its affiliates (called “Munson” in this Agreement) that all

employees, medical staff, students, volunteers, vendors, and any others who are permitted access, shall

protect and respect the privacy, confidentiality and security of all confidential information (“CI”).

CI includes: 1) patient information (such as medical records, billing records, and conversations about

patients), and 2) confidential business information of Munson (such as information concerning

employees, physicians, hospital contracts, financial operations, quality improvement, peer review,

utilization reports, risk management information, survey results, and research).

I understand and agree to only access, use or disclose CI for job related purposes, and will limit

access, use or disclosure to the minimal amount necessary to perform my job.

Further, I agree that:

1. I will protect the privacy and security of Munson information, including the electronic medical

record (EMR) in accordance with all Munson policies.

2. I will not access the EMR out of curiosity or concern (for example where a patient is a family

member, friend, child, ex-spouse, co-worker, neighbor or VIP), but only for a job related need.

3. I will not visit patients socially, for non- work related reasons, without first obtaining their

permission.

4. I will complete all required privacy and security training and annual HIPAA Healthstream training.

5. I will not maintain CI on a personal mobile device that is not encrypted and/or password protected.

6. I will not send CI by email unless properly encrypted.

7. I will not share passwords or allow EMR access to a computer under my login credentials.

8. I will not enter a restricted area in hospital without an official job related need or authorization.

9. I will not dispose of any paper or media with identifiable CI on it in the regular trash, but will use

shredders, confidential bins or Information Systems to destroy materials.

10. I will immediately report to my supervisor any suspected privacy or security breach, or privacy

error made in the course of normal scope of work.

11. I will safeguard all Munson and personal equipment from theft and improper use.

12. I understand that any Munson device may be audited, including access to medical records, use of

email and websites, and, that there is no expectation of privacy.

13. I understand that I am responsible for complying with all Munson privacy and security policies.

14. I understand that all privacy breaches are investigated, documented and reported and that

disciplinary consequences apply, up to and including termination. Civil fines or criminal penalties

may also apply.

15. I understand that my duty to maintain the confidentiality of information as described here remains in

effect even after leaving the Hospital.

I have read and understand the information noted above.

Your Signature_____________________________________________Date________________

Print your Name______________________________________Employee ID_______________

Please see attached sheet for examples of privacy breaches/ Please note the examples are not all inclusive. There are other examples.

Form #195 (02/15)

Confidentiality Agreement

HIPAA Privacy Protected Health Information (PHI) includes:

Patient name, address, DOB, social security number, all content of the medical record, medications etc.

Munson Policy adds additional disciplinary consequences for privacy violations involving mental health records,

substance abuse records, HIV status and other sensitive PHI.

Confidential Information is not to be shared inappropriately at work or away from work, via email, text, page,

written format, social media, photos, video, verbal disclosure, fax or other.

Examples of Privacy Breaches:

-Using the EMR to keep track of medical problems and care of estranged family members.

-Using the EMR to check on patients you used to care for but are now discharged or moved to another floor.

-Announcing patient name or diagnosis loudly in a lobby area.

-Verbal disclosure of lab results to others who are interested, but who have no job related need to know.

-Visiting a patient on a restricted unit, such as Maternity, without their permission.

-Visiting a co-worker who is hospitalized, without their permission.

-Borrowing someone’s password to access records or lending someone your password.

-Accessing a computer that is logged on under another’s password.

-Disposing anything with a patient name on it in regular trash.

-Mailing or giving Discharge Instructions or medications to the wrong patient.

-Faxing PHI without FAX COVER SHEET and/or to the wrong Fax number.

-Asking patients or visitors invasive questions such as “Why are you here?” or “What surgery are you having?”

-Accessing charts of ex -husbands or ex- girlfriends, etc, out of curiosity or concern, or to use in custody battle.

-Accessing chart to see why your co-worker is in the emergency department.

-Disclosing patient presence in hospital after they had “opted out” of facility directory.

-Leaving paper charts or census sheets open and unattended. Leaving PHI in hall, restroom or library.

-Talking about your patients in a public place like the cafeteria or hair-dressers, or grocery store.

-Sending wrong H&P home with patient.

-Talking about medical information in front of patient’s family without the patient’s permission.

Kim Benz, Manager Volunteer Services Ed Gilbert, Mission Services (231) 876-7149 or kbenz3@mhc.net (231) 876- 7738 egilbert@mhc.net

BACKGROUND CHECK INFORMATION

It is the practice of Munson Healthcare Cadillac Hospital to have a background check done as part of the screening

process. You will not be refused employment solely because of a conviction of a crime. Rather, the organization’s

decision will be determined on whether the conviction relates to the position applied for.

PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION: Name:______________________________________________________________________________ Last First Middle

Current Address:______________________________________________________________________

Street /City /State/ Zip Gender:___________________ Birthdate:__________________ S.S. #:__________________________

Names previously used:________________________________________________________________ If you have lived outside of the state of Michigan in the past 10 years, please list the city(ies) and state(s) in which you resided, along with time periods involved. City/State: ___________________________________________________________________________

Dates resided there: ___________________________________________________________________

City/State:___________________________________________________________________________

Dates resided there:___________________________________________________________________

City/State:___________________________________________________________________________

Dates resided there:____________________________________________________________________

To the best of my knowledge, the above information is accurate.

Signature/ Date _____________________________________/________________________ VSC10061 12/15

Statement of Understanding

Munson Healthcare Cadillac Hospital makes a large investment in each person who comes into our facility to volunteer. Therefore, it is important that each volunteer applicant understand and agree to the items listed below. Volunteer placement is contingent on acceptance in the program following successful completion of the interview and screening process.

In submitting this application, I agree to the following:

Volunteer service is provided to Munson Healthcare Cadillac Hospital with no remuneration. There is no association, either actual or implied, between Volunteer Services and employment with Munson Healthcare Cadillac Hospital.

I also understand that as a volunteer, I am not eligible for worker’s disability compensation benefits. If I am injured, I understand that payment for my medical treatment will be my responsibility through my private medical insurance or self-pay.

Volunteers do not have an advantage over other applicants for open positions with Munson Healthcare Cadillac Hospital.

Volunteer Services Department will not write letters of service confirmation for those who do not complete 100 hours of volunteer service.

After an interview, the average amount of time to complete the volunteer onboarding/placement process is 4-6 weeks. I understand that if I fail to complete each step in a timely manner or if my total onboarding time exceeds 6 weeks, Volunteer Services reserves the right to rescind the offer of placement in the Volunteer Program.

I understand that in order to continue in Munson Healthcare Cadillac Hospital Volunteer Services, my conduct must be satisfactory to the hospital, and that the Munson Healthcare Cadillac Hospital Volunteer Services Department reserves the right to terminate my volunteer status as a result of:

Failure to comply with hospital policies and procedures. Absences without prior notification. Unsatisfactory attitude, work or appearance. Any circumstances which in the judgment of the Munson Healthcare Cadillac

Hospital Volunteer Services Department Manager would make my continued service as a volunteer contrary to the best interests of the hospital.

June 1, 2016

Volunteer (Print Name) _________________________________ Date:__________________

Signature____________________________________________